76y · Female·Undetermined (natural causes)
… of insight and refusal of interventions, she was placed under a Mental Health Act order. She underwent gastroscopy for diagnostic purposes, could not be extubated post-procedure, and was admitted to ICU with type 2 res…
69y · Female·Complications of oesophageal squamous cell carcinoma (palliated)
… body dementia living in NDIS-funded supported accommodation, presented with dysphagia and weight loss. Gastroscopy revealed oesophageal squamous cell carcinoma with severe stricture. She was deemed not suitable for cur…
73y · Female·Metastatic oesophageal cancer
…ageal abnormality. She was admitted to hospital in March 2023 where oesophageal cancer was diagnosed on gastroscopy and biopsy. Oncology deemed the condition incurable and palliative care was initiated. An oesophageal s…
74y · Male·metastatic gastro-oesophageal adenocarcinoma
…astrointestinal symptoms from October 2018, was initially treated for Helicobacter pylori, but declined gastroscopy investigations initially. After progressive weight loss and swallowing difficulties, he underwent diagn…
49y · Male·Complications of metastatic gastric adenocarcinoma
…dominal pain and constipation on 10 August 2017, was investigated at Glen Inness District Hospital, and gastroscopy on 23 August revealed gastric malignancy. Following a large haematemesis on 26 August, he was transferr…
50y · Male·gastrointestinal haemorrhage; haemorrhage from cystic artery post laparoscopic c…
…ost-operative complications; inadequate investigation of suspected upper gastrointestinal bleeding with gastroscopy not performed when clinically indicated; incomplete handover of clinical information between teams; poo…
85y · Female·complications of oesophageal cancer
Dorothy Williams was an 85-year-old woman with intellectual impairment and dementia who died from complications of oesophageal cancer. She was diagnosed with inoperable oesophageal cancer in 2012 and managed palliatively…
47y · Female·hypoxic encephalopathy and aspiration pneumonia following aspiration of gastric …
… 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—a GP referral letter and CT…
80y · Male·aspiration pneumonia
…ndectomy. On hospital day 3, he developed coffee-ground vomitus indicating gastrointestinal bleeding. A gastroscopy was performed that afternoon to identify the bleeding source, but he aspirated gastric contents before …
52y · Female·Unascertained (natural causes)
…, and low iron stores, but no definitive diagnosis. Despite comprehensive workup including colonoscopy, gastroscopy, and bone marrow biopsy, the underlying cause remained unclear. She was appropriately transitioned to p…
52y · Female·end-stage liver failure and congenital hepatic fibrosis
Karenne King, a 52-year-old woman with intellectual disability living in Department of Human Services care, died from end-stage liver failure and congenital hepatic fibrosis. She had a long-standing history of congenital…
41y · Male·Aspiration pneumonitis in a setting of Lennox-Gastaut syndrome
…aspiration pneumonia after PEG feeding was recommenced. Despite insertion of a jejunal feeding tube via gastroscopy and multiple treatment modalities including antibiotics, steroids, oxygen, and physiotherapy, his condi…
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 jun…
62y · Male·Mediastinitis due to perforated oesophagus, with severe emphysema as a contribut…
…he was discharged without signs of perforation. He presented 4 days later with vomiting and chest pain; gastroscopy revealed deep longitudinal tears. The coroner found no fault with the discharge decision, noting the ex…
49y · Male·Complications in association with advanced gastric malignancy
…nal symptoms from 2009 onwards but initially declined investigations. When investigated in August 2013, gastroscopy and imaging revealed poorly differentiated gastric adenocarcinoma with gastric outlet obstruction and p…
48y · Male·Multi-organ failure from acute gastrointestinal haemorrhage associated with oeso…
Peter Tasman Cannell, aged 48, died in Flinders Medical Centre from multi-organ failure due to acute gastrointestinal haemorrhage from oesophageal varices on a background of liver cirrhosis. He had a medical history of h…
80y · Male·metastatic oesophageal cancer
…th progressive dysphagia, cough, and weight loss in mid-2020, which was appropriately investigated with gastroscopy, biopsy, and imaging confirming stage 4 cancer with hepatic metastases by October 2020. Medical care wa…
70y · Male·bronchopneumonia in a man with intra-abdominal carcinoma and multiple co-morbidi…
…recognition of acute coronary syndrome; (2) repeated refusals of diagnostic investigations (colonoscopy/gastroscopy) for anaemia, delaying cancer diagnosis; (3) inadequate staff appreciation of risks from unmonitored ox…
58y · Female·lymphangitic carcinomatosis leading to hypoxaemic respiratory failure and cardia…
…58-year-old woman presenting with weight loss, anorexia, and unexplained shortness of breath, underwent gastroscopy and colonoscopy at a private hospital to investigate suspected gastric pathology. She had hypoxaemia (o…
89y · Male·Complications of cerebrovascular accident (stroke); specifically a catastrophic …
… Enduring Power of Guardianship in the medical record, leading to cancellation of a medically indicated gastroscopy in September 2020; and inadequate family communication about his medical condition despite valid writte…
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