64y · Male·Foreign body associated small bowel obstruction
…bowel obstruction caused by a 45mm quartz-like stone he had ingested. Despite a known history of habitual foreign object swallowing requiring close supervision, and previous episodes of foreign body ingestion managed co…
1y · Female·Gastrointestinal haemorrhage due to aorto-oesophageal fistula caused by lodged b…
…o-oesophageal fistula and fatal gastrointestinal haemorrhage. Parents repeatedly expressed concerns about foreign body ingestion but these were not documented in medical records. The coroner found the emergency care was…
9y · Male·sigmoid volvulus
… 9-year-old Aboriginal boy with Goldenhar syndrome and developmental disability including pica (ingesting foreign substances), died from sigmoid volvulus complicated by ingestion of soil, sand, and stones. He was under …
26y · Male·shotgun wound of the chest
…Hobart Hospital on 2 January 2023 while under correctional officer supervision. He had been admitted for ingestion of foreign objects. Two correctional officers failed to follow security protocols: they removed his hand…
28y · Male·Peritonitis and septic shock complicating perforation of the terminal small bowe…
A 28-year-old man with cerebral palsy, microcephaly, and epilepsy presented to the ED with abdominal pain, fever, and signs of deterioration. Triaged as Priority 3 despite these concerning features, he was not seen by a …
4y · Female·Haemorrhage due to aorto-oesophageal fistula caused by ingestion of a button bat…
A 4-year-old girl died from aorto-oesophageal fistula and haemorrhage caused by a lithium button battery lodged in her oesophagus for at least 3 days. Critical diagnostic failures occurred: the initial GP failed to consi…
29y · Female·peritonitis caused by ischaemia of the bowel due to gastrointestinal torsion (tw…
Shona Hookey, a 29-year-old Aboriginal woman with severe intellectual disability and aphasia, died of peritonitis secondary to bowel torsion. Critical failures occurred at multiple levels: carers at her group home delaye…
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