Coronial

19 results for emergency hernia repair

VIChospital2011-09-22

Finding into death of Leanne Fiona MacKenzie

48y · Female·abdominal sepsis in a woman with coronary artery disease, post-repair small bowe…

…d with Prader-Willi syndrome and intellectual disability, underwent laparotomy for incarcerated incisional hernia on 3 April 2011 at Latrobe Regional Hospital with initial repair but poor postoperative progress. She deve…

general surgeryintensive care
NThospital2015-02-19

Inquest into the death of Desmond Tilmouth

50y · Male·myocardial infarction caused by coronary atherosclerosis

…coronary atherosclerosis complicated by end-stage renal disease and an incarcerated strangulated umbilical hernia. He died in custody at Alice Springs Hospital shortly after emergency hernia repair surgery. Despite pre-e…

surgeryanaesthesiaoxycodone
VIChospital2013-07-29

Finding into death of Beverley Pattinson

70y · Female·Severe dehydration and renal complications secondary to intestinal obstruction d…

…old woman presented to a rural hospital with 48 hours of vomiting and dehydration secondary to an inguinal hernia obstruction. The initial assessment by the hospital medical officer failed to adequately review ambulance …

emergency medicinegeneral practicediagnosticcommunicationmetoclopramide
VIChospital2021-02-10

Finding into death of MRWilson

43y · Male·Liver failure with cirrhosis in the setting of recent paracentesis and Hepatitis…

…n was a 43-year-old Aboriginal man with end-stage liver cirrhosis and hepatitis C who died 18 days after emergency umbilical hernia repair and one day after paracentesis drainage of 8 litres of ascites at a rural hospit…

gastroenterologyhepatologycommunicationmorphine
NSWhospital2024-01-29

Inquest into the death of Sean Montgomery

70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia

…an Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner identified multiple significant failings: the surgeon…

cardiothoracic surgerygeneral surgerydiagnosticcommunicationmorphine
TAShospital2018-12-05

Coroner's Finding: Suckling, James William

72y · Male·hypovolemic shock due to haemoperitoneum following surgical repair of an abdomin…

A 72-year-old man died from hypovolemic shock due to intra-abdominal haemorrhage following Spigelian hernia repair. Post-operatively he presented with hypotension, bradycardia and sweating. ECG changes were misinte…

surgeryemergency medicinediagnosticcommunicationmetaraminol
VIChospital2016-06-24

Finding into death of Wendy Elizabeth Pennycuick

65y · Female·Aspiration pneumonia following emergency laparotomy for incarcerated umbilical h…

…llectual disability, congenital blindness, diabetes, and epilepsy presented with an incarcerated umbilical hernia requiring emergency surgery. Post-operative aspiration occurred in recovery with subsequent aspiration pne…

colorectal surgeryintensive care
SAhospital2011-09-20

Coroner's Finding: BELLOCCO (aka Ieva) Carmelina

61y · Female·respiratory failure secondary to advanced malignancy

…longstanding paranoid schizophrenia with poor insight and compliance. Cancer was diagnosed in 2006 after emergency surgery for bowel obstruction; she refused adjuvant chemotherapy. In 2009, recurrent metastatic disease …

oncologycolorectal surgery
VIChospital2013-08-13

Finding into death of Thelma Katherine Holt

79y · Female·pneumonia in the setting of acute peritonitis due to perforated stomach (operate…

…cation, underwent placement of a second intragastric balloon on 11 September 2008 for weight loss prior to hernia repair. On 30 January 2009, she presented with severe abdominal pain and vomiting. CT imaging confirmed ga…

gastroenterologygeneral surgerydiagnosticproceduralsertraline
VIChospital2020-09-29

Finding into death of Nicola Deleo

91y · Male·Complications following cardiac arrest in the setting of anaesthetic induction d…

…xamethonium died from complications following anaphylaxis to rocuronium during anaesthetic induction for emergency small bowel obstruction surgery. His GP records documented allergy to both suxamethonium and vecuronium …

anaesthesiageneral surgerycommunicationsystemrocuronium
VIChospital2014-08-29

Finding into death of Noella Rae Clohesy

62y · Female·Multi-organ failure due to lacerated abdominal aorta complicating laparoscopic b…

A 62-year-old woman died from multi-organ failure caused by a lacerated abdominal aorta sustained during elective laparoscopic gastric band surgery in 2006. The aorta was cut by a Visiport trocar blade at the start of th…

general surgeryanaesthesiaproceduralcommunication
QLDhome2025-07-15

Inquest into the death of Daniel Thomas Wright

8y · Male·prematurity-associated lung and bowel disease

… his weight loss of 10% in final 10 days, indicating nutritional crisis, was not recognised as a medical emergency requiring admission; (2) growth charts were not consistently referenced to centiles despite available co…

neonatologypaediatricsdiagnosticcommunication
NThospital2009-11-27

Inquest into the death of Alma June Green

82y · Female·acute peritonitis, ruptured bowel and incarcerated bowel herniation

…ology department when left unattended with heavy IV pumps on her wheelchair, fracturing her hip. After hip repair, she developed vomiting on 11 November which was attributed to narcotic medication. Dr H., an intern, exam…

general surgeryradiologydiagnosticcommunicationoxycodone
TAShospital2016-06-27

Coroner's Finding: Mr P

64y · Male·Small bowel infarction due to a volvulus owing to adhesions in the small intesti…

Mr P, aged 64, presented to Royal Hobart Hospital's Emergency Department in October 2012 with severe central abdominal pain. The ED consultant diagnosed bowel obstruc…

emergency medicinegeneral surgerydiagnosticdelay
TAShospital2025-11-28

Coroner's Finding: Clark, Dennis

83y · Male·Sepsis due to staphylococcus aureus bacteraemia following infection of a left an…

…t oversight. The coroner found this preventable death occurred due to lack of identifying markers on the emergency line, absence of documented monitoring, and unclear protocol responsibility allocation.

emergency medicinesurgeryproceduralsystem
VIChospital2022-02-28

Finding into death of H YR

77y · Female·Haemoperitoneum following cholecystectomy

A 77-year-old woman died from haemoperitoneum (intra-abdominal bleeding) three days after elective laparoscopic cholecystectomy. Bleeding from the left inferior epigastric artery was a recognised surgical complication bu…

general surgeryintensive carediagnosticdelaywarfarin
NSWhospital2018-04-26

Inquest into the death of Margaret Ann Pegum

67y · Female·Sepsis as a result of gastric perforation

…after an intragastric balloon (IGB) procedure for weight loss. She had undergone fundoplication for hiatus hernia in 2012. Despite prior gastric surgery being an absolute contraindication to IGB placement—clearly documen…

gastroenterologybariatric surgerydiagnosticcommunication
SAhospital2003-05-08

Coroner's Finding: PRATT Shirley May

66y · Female·acute necrotising haemorrhagic mediastinitis

…nvasive procedures in rural settings must have formal transfer agreements with teaching hospitals, clear emergency protocols, and must take active responsibility for post-operative escalation decisions—not delegate this…

surgerygeneral surgerycommunicationsystemfentanyl
WAhospital2007-06-08

Inquest into the Death of Rasmussen

31y · Female·cerebral anoxia following attempted intubation pre-surgery in a woman with torti…

…xia following attempted intubation at Joondalup Health Campus. She was admitted for elective left inguinal hernia repair. Dr L., the anaesthetist, administered the intermediate-acting muscle relaxant Atracurium without f…

anaesthesiageneral surgerydiagnosticproceduralatracurium

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