68y · Female·haemopericardium resulting from perforation of the pericardial sac during laparo…
Mrs Christine Flynn, aged 68, died from haemopericardium and pericardial tamponade following laparoscopic hiatus hernia repair. A 2mm perforation of the pericardial sac occurred during surgery, likely from mesh tacks pl…
72y · Male·Complications of small bowel obstruction in a man with multiple medical co-morbi…
…ith intellectual disability, schizophrenia, recurrent DVT, cardiomegaly, COPD, ischaemic heart disease and hiatus hernia, presented to Austin Hospital with nausea, vomiting and decreased appetite. CT imaging revealed hig…
75y · Female·Airway obstruction due to aspiration occluding a permanent tracheostomy
…acheostomy. She had a history of subglottic stenosis, asthma, and gastro-oesophageal reflux disease with a hiatus hernia. Despite district nursing care three times weekly and two ambulance attendances on 11-12 September …
69y · Female·unascertained
… 69, died of an unascertained cause on the evening of discharge following laparoscopic cholecystectomy and hiatus hernia repair at Fremantle Hospital. She was observed at 2pm with tachycardia (HR 111) and pain (10/10), g…
90y · Male·Complications following aspiration of food
Donald Walter Thoms, 90 years old with intellectual disability and high aspiration risk, died from complications following aspiration of food while in specialist disability residential care. He was on a pureed diet and t…
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…
55y · Male·recurrent aspiration pneumonia in a man with severe intellectual disability comp…
Jonathan Smith, a 55-year-old man with severe intellectual disability due to childhood encephalitis, died from recurrent aspiration pneumonia. He had experienced three episodes within a year prior to death. After admissi…
68y · Male·pulmonary thromboembolism in the setting of recent surgery
A 68-year-old man died from pulmonary thromboembolism following revisional gastric bypass surgery. He developed multiple post-operative complications including fever, elevated inflammatory markers, and a possible bowel p…
57y · Female·Pulmonary thromboembolism
Ann-Maree Manno, 57, died from pulmonary thromboembolism 8 days after laparoscopic gastric band surgery. She had significant risk factors: obesity (BMI 37.9), history of unprovoked DVT in 2007 and 2016, and recent surger…
85y · Female·sepsis, with aspiration pneumonitis being an antecedent cause. Iatrogenic injury…
…ed on 30 April 2016 to provide enteral nutrition but was incorrectly positioned in the right lung due to a hiatus hernia and software error when reviewing chest x-rays (Dr N. and Dr C. reviewed the wrong x-ray image). Co…
62y · Female·gastric necrosis and perforation due to strangulated diaphragmatic hernia
Joyce Wilman, 62, died from gastric necrosis and perforation due to strangulated para-oesophageal hernia whilst detained under Mental Health Act at Queen Elizabeth Hospital. She presented with vomiting and abdom…
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…
80y · Male·General inanition due to advanced Alzheimer's dementia
Phillip Maxwell Hayden, aged 80, died of general inanition due to advanced Alzheimer's dementia at a nursing home. He had been admitted to hospital in June 2014 with behavioural and psychological symptoms of dementia, re…
57y · Male·aspiration pneumonia in an intellectually disabled man
Stewart Padgham, a 57-year-old man with severe intellectual disability, epilepsy, and multiple comorbidities, died from aspiration pneumonia. He presented with vomiting, difficulty swallowing, and respiratory symptoms on…
67y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …
David Fensom, 67, underwent elective fundoplication for hiatus hernia and reflux on 21 September 2010. He developed severe right-sided abdominal pain post-operatively. A…
69y · Female·Aspiration pneumonia in a woman with intellectual disability
Elizabeth Geiger, a 69-year-old woman with intellectual disability living in a disability group home, died from aspiration pneumonia after presenting with constipation. She was seen by her GP on 24 July 2017 who examined…
74y · Female·Chronic obstructive pulmonary disease
Judith Gail Longhurst, a 74-year-old woman with cerebral palsy, dysphagia, and multiple comorbidities, died of chronic obstructive pulmonary disease (COPD) on 23 October 2024 at her Specialist Disability Accommodation re…
74y · Male·Small bowel obstruction due to extensive intra-abdominal adhesions
Timothy Funder, a 74-year-old man with schizophrenia, chronic obstructive pulmonary disease, and previous small bowel obstruction, died from small bowel obstruction due to extensive intra-abdominal adhesions. He presente…
66y · Female·Complications of pulmonary fibrosis and bronchiectasis in a woman with cerebral …
Linda Stanton, a 66-year-old woman with cerebral palsy, pulmonary fibrosis, and bronchiectasis, died from complications of her lung disease. She had required six hospital presentations between December 2015 and August 20…
72y · Female·Pneumonia as a consequence of chronic obstructive airway disease
Ms Vigor-Newitt, a 72-year-old woman in prison, died from pneumonia complicated by chronic obstructive airway disease. She had presented with respiratory symptoms on 27 and 29 September 2020 and was appropriately hospita…
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