62y · Female·Complications arising from elective laparoscopic Hartmann's procedure for recurr…
…m complications following an elective laparoscopic Hartmann's procedure for recurrent sigmoid volvulus and ileus. Post-operatively uncomplicated initially, she deteriorated on day 3 with signs of sepsis (diaphoresis, di…
71y · Male·Aspiration in setting of paralytic ileus in patient in convalescent phase of abd…
A 71-year-old man died from aspiration complicating prolonged paralytic ileus on postoperative day 9 following open abdominal aortic aneurysm repair. Despite clinical signs of persiste…
42y · Male·Aspiration pneumonia complicating small bowel ileus in a man with cerebral palsy
…miting, abdominal distension and pain on 21 October 2019. Investigations revealed small bowel obstruction (ileus). Despite admission under General Medicine, his condition deteriorated rapidly, developing aspiration pneu…
57y · Male·sepsis and multiple organ failure secondary to aspiration pneumonia
…hy Fenton, a 57-year-old intellectually disabled man on antiepileptic medications, developed a small bowel ileus after presenting with vomiting and diarrhoea. Following emergency laparotomy, his nasogastric tube was dis…
59y · Male·Massive aspiration in the setting of intubation following complications of sever…
…ent-resistant schizophrenia on long-term clozapine therapy died from massive aspiration following a severe ileus of unknown aetiology. He had documented constipation managed with laxatives, then developed progressive ab…
82y · Male·complications from multiple injuries received in a motor vehicle accident
…s old, died from complications of multiple injuries sustained in a motor vehicle accident. He developed an ileus or pseudo-colonic obstruction requiring nasogastric tube (NGT) insertion. The key clinical issue was Dr H.…
80y · Male·asphyxia due to choking on food
…rs by GP, bladder distension (3750 ml urine), urinary obstruction from enlarged prostate causing paralytic ileus increasing aspiration risk. The coroner found medical care at hospital appropriate. Key lessons: mental he…
80y · Male·aspiration pneumonia
…e enabled earlier nasogastric tube insertion and reduced aspiration risk; (3) The possibility of paralytic ileus was not considered until the following day; (4) Medical records with illegible handwriting significantly h…
80y · Female·sudden cardiac arrest due to multiple post-operative complications including myo…
…complex 8-hour surgery complicated by extensive adhesions (frozen pelvis). Post-operatively, she developed ileus and was transferred to a tertiary hospital for TPN and bowel stimulation. She had an undiagnosed long QT s…
74y · Male·Aspiration of gastric contents due to paralytic ileus following Whipple surgery …
… occurred: on the evening of 1 March when abdominal distension and respiratory distress were attributed to ileus without consideration of NGT reinsertion; at 4:17am on 2 March despite clinical deterioration and abnormal…
84y · Female·small bowel obstruction due to gallstone ileus
…resented a third time in extremis with asystole and died despite resuscitation. Autopsy revealed gallstone ileus causing small bowel obstruction. While the coroner found the initial management reasonable, the case highl…
58y · Male·Aspiration pneumonia complicating small bowel obstruction in the setting of rece…
A 58-year-old man died from aspiration pneumonia complicating small bowel obstruction six days after elective laparoscopic subtotal colectomy for colorectal cancer. On post-operative day 6, he developed fever, tachycardi…
49y · Male·unascertainable; possible explanations include epileptic seizure, cardiac arrhyt…
… unascertainable cause. Possible explanations included epileptic seizure, cardiac arrhythmia, or paralytic ileus, with contributing factors potentially including recent clozapine initiation (June 2005), constipation man…
80y · Male·Vasodilatory shock and multi-organ failure secondary to aspiration and cardiores…
… cardiopulmonary arrest in hospital following colorectal cancer surgery. He had developed a post-operative ileus requiring nasogastric tube placement, which was removed on 4 June when he appeared to be recovering. That …
80y · Female·peritonitis due to sigmoid resection margin leak following extended right hemico…
…ing this to GP Dr C. who did not follow up. Diagnosis was delayed five months. Post-operatively, paralytic ileus on day 2 should have prompted CT imaging to exclude anastomotic leak, but this was not performed. The pati…
54y · Male·Complications including hepatic encephalopathy, pneumonia and multi-organ failur…
Wayne Frederick Leese, a 54-year-old prisoner, died from complications of hepatitis C and hepatocellular carcinoma including hepatic encephalopathy, pneumonia and multi-organ failure. He collapsed at Acacia Prison on 4 M…
60y · Female·Cardiac tamponade due to ruptured heart due to total parenteral nutrition due to…
A 60-year-old woman died from cardiac tamponade caused by TPN fluid leaking into the pericardium through a PICC line inserted to provide nutrition following bowel surgery. The PICC line was inserted under image intensifi…
42y · Male·Aspiration pneumonia in the setting of impacted large bowel in a man with intell…
Chris Perdios, a 42-year-old man with intellectual disability, autism, and chronic constipation, died from aspiration pneumonia complicated by an impacted large bowel. He was admitted to hospital on 12 October 2018 with …
76y · Male·multiple organ failure due to large volume aspiration of gastric contents during…
Maurice Nancarrow, 76, died from multiple organ failure following aspiration of gastric contents during anaesthetic induction for cystoscopy on 15 August 2015. He had undergone colorectal surgery on 30 July with complica…
67y · Female·ischaemic heart disease
Merren Elizabeth Bartley, a 67-year-old woman with schizophrenia managed with clozapine and multiple comorbidities including coronary artery disease, died of ischaemic heart disease while an inpatient at a mental health …
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