Coronial
VICaged care2012-08-20

Finding into death of Andrew Wilson

44y · Male·aspiration and intellectual disability

…ere scoliosis, died from aspiration in a community residential unit. He had been prescribed a laxative and enema for constipation after having faecal loading identified. He subsequently vomited twice and developed shall…

gastroenterologygeneral practicelamotrigine
QLDhospital2007-05-04

Horsington, Margaret Isabel

83y · Female·cardiac arrest from severe triple vessel coronary artery disease complicated by …

…ma Hospital with constipation and was diagnosed appropriately, but clinical management deteriorated. Fleet enema was administered despite prior failed bowel clearance attempts, worsening abdominal distension and compres…

general surgeryemergency medicinediagnosticcommunicationfleet
TASaged care2018-01-29

Coroner's Finding: Ball, Betty Irene

67y · Female·perforated sigmoid volvulus with peritonitis upon a background of spinocerebella…

Betty Irene Ball, aged 67, died from perforated sigmoid volvulus with peritonitis on 2 February 2016. She had spinocerebellar ataxia and was resident in aged care. She developed constipation from 15 January 2016, but med…

general practiceemergency medicinedelaysystemparacetamol
WAhospital2023-06-29

Inquest into the Death of Child R (Name Subject to Suppression Order)

11y · Female·Complications of E. coli sepsis in association with intestinal obstruction due t…

…ction of megacolon. Critical delays in management included: a three-hour delay administering the phosphate enema after consultant recommendation at 8:30am; unclear handover of care between two doctors creating a gap in …

paediatricsemergency medicinediagnosticcommunicationmacrogol
VIChospital2022-11-29

Finding into death of Paul Desmond Smith

58y · Male·complications of large bowel pseudo-obstruction

…k factors for recurrent obstruction, he was discharged after only symptomatic treatment with laxatives and enema. The morning ward round assessment was cursory, with minimal documentation and no appreciation of his high…

general surgerycolorectal surgerydiagnosticcommunicationmacrogol
QLD2007-11-28

Tanner, Marjorie Joyce

Female·Coronary atherosclerosis with ischaemic small bowel and Alzheimer's disease

…of abdominal pain, distension, and vomiting. Initially diagnosed with simple constipation and treated with enema and laxatives, she was discharged then readmitted when symptoms persisted. At Hervey Bay Hospital, bowel o…

general medicinesurgerydiagnosticsystemmetoclopramide
NSWhospital2010-12-21

Coroner's Finding: Joan Dennison

78y · Female·sepsis and aspiration with metabolic dysfunction as a result of mechanical small…

…ngs, failure to review the radiologist's formal report, and acceptance of an inappropriate treatment plan (enema). The surgical registrar failed to view available x-rays despite direct access through the PACS system and…

emergency medicinegeneral surgerydiagnosticcommunicationmetoclopramide
QLDhospital2014-03-31

Platt, Christopher Robert Edmund - Non-inquest findings

69y · Male·Perforated bowel/septicaemia as a result of diverticulitis

…ngs suggestive of small bowel obstruction, low albumin, tachypnoea, low oxygen saturations); inappropriate enema administration which may have been harmful; delayed x-ray reporting; poor clinical handover and documentat…

emergency medicinegeneral surgerydiagnosticcommunicationsodium citrate enema
WAhospital2020-08-13

Inquest into the Death of Susan Jessica Elsie WINDIE

22y · Female·bowel obstruction due to faecal impaction

Susan Windie, a 22-year-old with rare congenital abnormalities affecting bowel function, died from bowel obstruction due to faecal impaction complicated by abdominal compartment syndrome. She presented to Carnarvon Hospi…

gastroenterologygeneral practicecommunicationsystemfleet enema
VIChospital2016-05-12

Finding into death of Kevin Stanley Margetts

63y · Male·Bowel obstruction

A 63-year-old man with severe intellectual disability, quadriplegia, and blindness died from bowel obstruction with sepsis. On 5 September 2015, carers noted cough and eating difficulties. A locum doctor visited, noted h…

general practiceemergency medicinedelaysodium citrate enema
SAhospital2001-12-14

Coroner's Finding: OVERLAND Harold Kelvin

74y · Male·myocardial infarction

A 74-year-old male aged care resident died of myocardial infarction while detained under the Mental Health Act at Royal Adelaide Hospital. He had presented with hypokalaemia and sigmoid volvulus, refusing initial treatme…

emergency medicinecardiologyproceduralcommunication
WAmental health2014-04-11

Inquest into the Death of Ritchie GORDON

49y · Male·unascertainable; possible explanations include epileptic seizure, cardiac arrhyt…

…tors potentially including recent clozapine initiation (June 2005), constipation managed with laxative and enema, developmental brain abnormality, and ischaemic heart disease identified at autopsy. The coroner found he …

psychiatryforensic medicineclozapine
SAhospital2018-02-05

Coroner's Finding: SISSONS Anthony Vincent

38y · Male·metastatic poorly differentiated carcinoma on a background of delirium and schiz…

Anthony Sissons, aged 38, died of metastatic renal carcinoma while under a Mental Health Act inpatient treatment order. He presented to hospital on three separate occasions (13-15 June 2012) with constipation, which was …

general practiceemergency medicinediagnosticzuclopenthixol
VIChospital2015-09-07

Finding into death of Jay Dion Sykes

18y · Male·Aspiration pneumonia in a setting of acquired brain injury from non-accidental h…

Jay Dion Sykes, aged 18, died from aspiration pneumonia in the setting of acquired brain injury sustained non-accidentally as an infant. He had severe cerebral palsy, tetraparesis, aphasia, visual impairment, intellectua…

general medicineemergency medicinecommunicationesomeprazole
VICmental health2013-07-26

Finding into death of Amy Hauserman

26y · Female·Hypoxic brain injury in the setting of immersion

Amy Hauserman, a 26-year-old woman with schizophrenia and anorexia, was admitted to a psychiatric ward with acute psychosis due to non-compliance with clozapine. Over two days, she developed severe abdominal pain and con…

psychiatryforensic medicinediagnosticcommunicationclozapine
SAhospital2013-09-30

Coroner's Finding: GIANNINI Pasquale

68y · Male·infarction of the small and large bowel due to superior mesenteric artery thromb…

A 68-year-old man with extensive systemic vascular disease presented with 10 days of nonspecific abdominal pain. Initial presentations at local hospital and GP were attributed to possible gallstones or gastritis based on…

general practiceemergency medicinediagnosticdelayaugmentin duo
NSWhospital2018-06-06

Inquest into the death of Dr Malay Rana

27y · Male·Loss of airway control and blockage due to aspiration from complications of a sm…

Dr R., a 27-year-old physician with cystic fibrosis, died from aspiration and airway blockage secondary to a small bowel obstruction whilst under dual respiratory-surgical care at Westmead Hospital. Critical clinical les…

respiratory medicinegeneral surgerycommunicationdiagnosticfentanyl
VIChospital2013-07-29

Finding into death of Beverley Pattinson

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

A 70-year-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 …

emergency medicinegeneral practicediagnosticcommunicationmetoclopramide
QLDaged care2025-04-17

Non-inquest findings into the death of Mr H.

89y · Male·combination of biochemical consequences of colonic pseudo-obstruction and faecal…

An 89-year-old man with multiple comorbidities including previous colon cancer died from faecal impaction and stercoral colitis. He resided in a residential aged care facility (RACF) where staff failed to recognize that …

geriatric medicinegeneral practicediagnosticcommunicationmacrogol

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