70y · Female·Perforated diverticulitis
… order and Medical Power of Attorney), surgical intervention was not pursued. She died from perforated diverticulitis. The coroner found no evidence of want of clinical management or care by either the disability accommo…
69y · Male·Perforated bowel/septicaemia as a result of diverticulitis
…. He returned 2 days later critically unwell and died of perforated bowel and septicaemia secondary to diverticulitis. Critical failures included: missing early signs of serious intra-abdominal pathology (elevated WCC, x…
Male·Faecal peritonitis due to perforated diverticulum
…erland presented to Bega Hospital Emergency Department on 2 March 2006 with severe abdominal pain from diverticulitis with bowel perforation. Dr B., the attending Career Medical Officer, formed an unfounded belief the pa…
80y · Female·sudden cardiac arrest due to multiple post-operative complications including myo…
…woman died from multiple post-operative complications following reversal of a Hartmann's procedure for diverticulitis. She had undergone a complex 8-hour surgery complicated by extensive adhesions (frozen pelvis). Post-o…
65y · Male·Unascertained (Natural Causes) - most likely myocardial infarction or pulmonary …
Brian Livingstone Clark, aged 65, died of natural causes while residing in specialist disability accommodation. He had early-onset Alzheimer's disease diagnosed in May 2023 and required full-time care. On 18 June 2025, s…
88y · Female·sepsis of unknown origin
…orating vital signs, transferred to hospital with sepsis of unknown origin (possibly perforated bowel, diverticulitis, colitis, or ischaemic bowel). Clinical lesson: early recognition of physical illness in elderly patie…
84y · Male·Chronic small bowel obstruction
Lester Gilmore Shelton, aged 84, died of chronic small bowel obstruction on 4 October 2022 whilst in custody at Princess Alexandra Hospital (PAH), where he had been transferred from prison for end-of-life care. He had a …
67y · Male·acute gastrointestinal haemorrhage complicating peptic ulcer of the duodenum wit…
…odenal ulcer following complex post-operative complications from laparoscopic Hartmann's procedure for diverticulitis. Key clinical lessons: (1) Early persistent elevation of C-reactive protein post-colorectal surgery is…
85y · Female·sepsis, with aspiration pneumonitis being an antecedent cause. Iatrogenic injury…
Lorraine Barnes, an 85-year-old woman admitted to Wollongong Private Hospital for convalescence, died from sepsis with aspiration pneumonitis following iatrogenic lung injury. She developed severe malnutrition and electr…
90y · Female·Choking
A 90-year-old woman with dysphagia died from choking after consuming thin fluid (coffee) against medical recommendation. She had been reviewed by a speech pathologist on 15 November 2024 who recommended thick fluids only…
88y · Male·General frailty and inanition; antecedent conditions: chronic cardiac and renal …
David Grahame Jones, aged 88, died in custody at Kevin Waller Aged Care Unit, Long Bay Correctional Centre from general frailty and inanition due to chronic cardiac and renal failure and diabetes. The coroner found he re…
83y · Male·Intracranial haemorrhage
Roger Rogerson, aged 83, died from intracranial haemorrhage due to cerebral amyloidosis while in custody at Long Bay Correctional Centre. He had been an inmate for nearly ten years. His condition deteriorated significant…
90y · Female·abdominal sepsis complicating perforated diverticular abscess of the sigmoid col…
Thelma Annie Ogilvy, a 90-year-old woman from rural Victoria, died from abdominal sepsis complicating a perforated diverticular abscess. She presented with bowel obstruction requiring laparotomy on 21 October 2019, was d…
49y · Male·pneumonia, hypoxic brain injury and cardiac arrest
49-year-old male with chronic cannabis dependence and depression developed post-surgical delirium following emergency anterior resection for perforated diverticulum. He became acutely agitated and paranoid, was detained …
76y · Male·multiple organ failure due to large volume aspiration of gastric contents during…
Maurice Nancarrow, 76, died from multiple organ failure following aspiration of gastric contents during anaesthetic induction for cystoscopy on 15 August 2015. He had undergone colorectal surgery on 30 July with complica…
86y · Male·Sepsis with septic shock, due to urinary tract infection, pyelonephritis (kidney…
An 86-year-old man died from sepsis and septic shock secondary to urinary tract infection, pyelonephritis and prostatic infection. He presented to his GP in March 2015 with dizziness and reported urinary incontinence and…
42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…
…uded: (1) failure to document and investigate differential diagnoses (bowel obstruction, pancreatitis, diverticulitis); (2) no vital signs recorded for 12 hours despite yellow-zone temperature; (3) failure of on-call doc…
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