74y · Female·Cardiac arrest due to pulmonary embolism secondary to deep venous thrombosis
…ound was scheduled for the next morning. Anticoagulation was not administered due to concern about recent gastric ulcer bleeding and recurrent H. pylori. That night she collapsed and died from pulmonary embolism seconda…
43y · Male·Unascertained - attributed to metabolic/physiological derangement in context of …
…nd paramedics arrived promptly, but resuscitation was unsuccessful. Autopsy revealed a perforated chronic gastric ulcer, dehydration, and various drugs including methamphetamine and morphine, but the exact cause of deat…
67y · Female·perforated gastric ulcer; morphine toxicity also made a significant contribution
… pain and potentially masking symptoms of perforation. The patient died 2.5 hours later from a perforated gastric ulcer, with morphine toxicity significantly contributing. Key failures: inadequate examination and diagno…
60y · Male·ischaemic heart disease due to severe single vessel atherosclerosis
…017 reporting chest pain, nausea, and shoulder pain. The GP attributed the chest pain to his pre-existing gastric ulcer and reflux, and the arm pain to increased use following recent surgery. The coroner found that with…
48y · Male·sepsis and renal failure due to perforated gastric ulcer
…ghout the afternoon, imaging showed only faecal loading and constipation was diagnosed. A ruptured pyloric ulcer causing peritonitis was not recognised until 9pm when he was found on the floor in shock. Transfer to the …
84y · Male·Acute myocardial infarction precipitated by upper gastrointestinal haemorrhage f…
…ban cannot be monitored or reversed, unlike warfarin. He developed upper gastrointestinal bleeding from a gastric ulcer, possibly exacerbated by concurrent use of a naturopathic cherry juice product and rivaroxaban. Sym…
47y · Female·hypoxic encephalopathy and aspiration pneumonia following aspiration of gastric …
…e Ann Pearson, aged 47, died from hypoxic encephalopathy and aspiration pneumonia following aspiration of gastric contents during a gastroscopy at Belmont Hospital on 15 February 2016. Critical pre-procedure information…
83y · Female·upper gastrointestinal bleed with haemodynamic compromise following anticoagulat…
…r documented as withheld, despite no clear clinical rationale. The coroner accepted expert opinion that a gastric or duodenal ulcer causing the fatal haemorrhage would likely have been prevented had PPI therapy continue…
34y · Male·extensive blood loss from acute gastric erosions following severe scalding of th…
… a 34-year-old man with intellectual disability, epilepsy, and vision/hearing impairment, died from acute gastric erosions following severe scalding injuries sustained on 29 November 1999. He was scalded to 17.5% of his…
69y · Male·Haemopericardium secondary to ischaemic heart disease
Brian Matthew McDonald, a 69-year-old man with autism, intellectual disability, and epilepsy living in specialist disability accommodation, died from haemopericardium secondary to ischaemic heart disease. He collapsed in…
57y · Female·small bowel ischaemia; distal gastrectomy
57-year-old woman underwent distal gastrectomy and vagotomy for gastric outlet obstruction in August 2008. Coroner found she suffered an aberrant surgical reconstruction during …
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…
70y · Male·gastrointestinal haemorrhage in a man with gastric ulcers
…im home. The deceased deteriorated and died two days later from gastrointestinal haemorrhage secondary to gastric ulcers with arterial erosion. Expert evidence confirmed a doctor at Dr H.'s level should have made the co…
89y · Male·Complications of cerebrovascular accident (stroke); specifically a catastrophic …
…ticoagulation therapy to prevent embolic stroke against his high gastrointestinal bleeding risk following gastric ulcers and his frequent falls. His anticoagulant (apixaban) was withheld from July 2021 onwards due to bl…
61y · Male·pulmonary thromboembolus
…cal factors included post-operative complications from laryngectomy, which he complicated by refusing nasogastric feeding and adequate tracheostomy care. The coroner found no evidence of inadequate medical care, noting …
63y · Male·Respiratory failure due to acute exacerbation of chronic obstructive airways dis…
Lewis Chetcuti, 63-year-old involuntary psychiatric patient with longstanding schizophrenia and significant comorbidities including severe COPD, congestive cardiac failure and chronic renal failure, died from respiratory…
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…
83y · Female·unascertained
Felicity Ruth Loveday, aged 83, disappeared and is presumed deceased after setting sail from Port Phillip Bay on 11 December 2019 with her son. Ms Loveday had significant medical and cognitive vulnerabilities including s…
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