62y · Male·Acute Gastrointestinal Haemorrhage in association with Acute on Chronic Peptic U…
… or lower GI, and the assumption among registrars that investigation could wait until morning, no urgent endoscopy was arranged overnight. He deteriorated around 08:00 hours on 13 April 2006 and became haemodynamically …
72y · Female·haemorrhage from penetrating duodenal ulcer
…dmitting medical team. Despite a positive faecal occult blood test and clinical evidence of bleeding, no endoscopy was performed. The team attributed symptoms to cardiac pathology based on elevated cardiac enzymes, whic…
56y · Male·aspiration pneumonitis secondary to airways obstruction from squamous cell carci…
…ign (dental abscess, rib fracture). Critical delay occurred: swallowing difficulties were documented but endoscopy not arranged until February 2020, despite symptoms from September. A CT scan ordered in November was can…
64y · Male·hospital-acquired pneumonia on a background of end-stage cryptogenic liver cirrh…
…al Health Act to enable necessary medical interventions including nasogastric feeding, paracentesis, and endoscopy. Hospital-acquired pneumonia developed on day 9 of treatment, possibly following endoscopy, and progress…
29y · Male·aspiration pneumonia complicating acute and chronic Wernicke's encephalopathy an…
… 2004, initially attributed to psychiatric illness (depression/catatonia) rather than organic causes. An endoscopy showed Helicobacter pylori infection but this finding was not clearly communicated to the psychiatrist. …
65y · Male·Bleeding duodenal ulcer
…tively conveyed to the treating team. This diagnostic failure resulted in failure to escalate for urgent endoscopy or surgical intervention, making the death preventable. The coroner identified premature diagnostic clos…
66y · Male·metastatic oesophageal cancer
…ed with weight loss and dysphagia in late 2016, was investigated at Royal Adelaide Hospital where CT and endoscopy confirmed advanced oesophageal adenocarcinoma with metastatic disease to lungs, liver, spleen and lymph …
81y · Male·gastrointestinal haemorrhage and multi-organ failure on a background of severe d…
…urgery. Despite efforts to manage his care in hospital, he refused investigation and treatment including endoscopy. His declining physical health, weight loss, anaemia, cardiac failure, and swallowing difficulties progr…
50y · Male·multi-organ failure due to pancreatitis and generalised varicella zoster virus i…
… admitted to hospital for a routine bone marrow biopsy but presented with severe abdominal pain. Despite endoscopy, varicella with pancreatic involvement was not immediately identified. He suffered two seizures, episode…
67y · Male·hypoxic respiratory failure in the setting of pneumonia, pulmonary embolism and …
…atala Labour Prison and received significant medical care including chemoembolisation, radiotherapy, and endoscopy for liver cancer discovered incidentally in 2021. In December 2022, he presented with chest pain and was…
79y · Male·Multi-organ failure due to pneumonia and bleeding duodenal ulcer complicating su…
… Health Act detention. Despite appropriate medical management including antibiotics, blood transfusions, endoscopy with haemostasis, and nasogastric feeding, he deteriorated from multi-organ failure. The coroner found n…
33y · Female·Hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiop…
…review a deteriorating patient in the ward despite nursing requests. The glycoprep bowel preparation for endoscopy likely accelerated decompensation. The coroner found systemic issues including incomplete transfer summa…
65y · Female·gastrointestinal haemorrhage from duodenal ulcer
…s allowed nursing staff to mismanage oxygen levels despite clear documentation; (3) the decision against endoscopy was medically sound given severe respiratory compromise, but conservative treatment with IV Nexium and t…
49y · Male·small intestinal infarction due to mesenteric and portal vein thrombosis associa…
Gary Walpole, a 49-year-old teacher with polycythaemia rubra vera, died from small intestinal infarction due to mesenteric and portal vein thrombosis. He was admitted to Royal Adelaide Hospital with oesophageal varices f…
66y · Female·acute necrotising haemorrhagic mediastinitis
Mrs Pratt, aged 66, underwent elective gastroscopy at Kapunda Hospital. During the procedure she heaved, and blood was noted at the gastro-oesophageal junction. She was discharged the same afternoon with pain, only to re…
64y · Male·aspiration pneumonia following insertion of a jejunostomy tube
Ronald Brockel, a 64-year-old with cerebral palsy, oropharyngeal dysphagia, and recurrent aspiration pneumonia, underwent insertion of a feeding jejunostomy tube (FJT) on 23 December 2004 to bypass his stomach and improv…
56y · Male·Liver cancer (hepatocellular carcinoma)
Phillip John Wust, a 56-year-old prisoner with chronic hepatitis C and cirrhosis, died from hepatocellular carcinoma. Serial imaging from 2018-2019 showed cirrhosis but no evidence of cancer until December 2019 when he p…
76y · Male·Terminal pancreatic cancer
76-year-old Robert Leonard Morris died from terminal pancreatic cancer while serving a custodial sentence at Port Phillip Prison. He had been diagnosed with inoperable pancreatic adenocarcinoma in December 2020 and comme…
57y · Male·Bleeding oesophageal varices due to cirrhosis and metastatic hepatocellular carc…
A 57-year-old prisoner with hepatitis C, cirrhosis, and advanced hepatocellular carcinoma died from bleeding oesophageal varices. He was appropriately managed with aggressive treatment including TACE and variceal ligatio…
64y · Male·Consequences of metastatic oesophageal carcinoma with Stanford B dissection thor…
Jose Manuel Xavier, a 64-year-old prisoner, died from metastatic oesophageal carcinoma with a contributing Stanford B thoracic aortic dissection. He was diagnosed with oesophageal cancer in July 2019 after presenting wit…
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