Coronial

13 results for interventional radiology procedure

VIChospital2011-07-06

Finding into death of Tzu Lin Yang

59y · Female·multi-organ failure as a result of metastatic cervical cancer

…t and refusal of treatment, guardianship and involuntary treatment orders were obtained. She underwent interventional radiology for haemorrhage control and a NFR order was established with family consent. She deteriorate…

oncologypsychiatryolanzapine
VIChospital2023-10-30

Finding into death of BCT

2y · Unknown·Hypoxic-ischaemic encephalopathy following sepsis related to abdominal surgical …

… following sepsis related to bowel perforation after a percutaneous endoscopic gastrojejunostomy (PEG-J) procedure. Critical failures included: delay in recognising bowel perforation as the cause of clinical deteriorati…

gastroenterologyradiologydiagnosticcommunicationceftriaxone
VIChospital2022-05-06

Finding into death of Trevor Anthony Peterson

57y · Male·Sepsis from ischemic bowel due to superior mesenteric artery thrombus

…mic bowel. Key learning: ensure explicit communication of critical post-procedural medications between interventional radiologists and treating teams; improve patient education about medication adherence; and consider ea…

vascular surgeryradiologycommunicationsystemaspirin
QLDhospital2025-06-02

Non-inquest findings into the death of Mr B.

42y · Male·Multiple organ failure due to iatrogenic phenol overdose due to metastatic pancr…

… intended 10% phenol concentration. Key clinical lessons include: (1) radiologists performing unfamiliar procedures must actively seek detailed knowledge from literature and colleagues, not assume medication is pre-prep…

radiologyintensive carediagnosticmedicationphenol 80%
TAShospital2015-06-16

Coroner's Finding: Sansom, Ann Margaret

62y · Female·acute subarachnoid haemorrhage following perforation of the anterior communicati…

…id haemorrhage following perforation of the anterior communicating artery during an endovascular coiling procedure for a 3mm berry aneurysm. The aneurysm was discovered incidentally when she presented with third cranial…

radiologyneurosurgeryheparin
QLDhospital2017-10-23

Non Inquest Findings TO

73y · Male·Sepsis (gram-negative septic shock) secondary to complications of selective inte…

…e internal radiation therapy (SIRT) for metastatic gastric cancer. He had previously undergone a Whipple procedure in 2014, which creates a direct communication between bowel and bile duct, increasing infection risk. Po…

radiologyemergency medicinediagnosticmedication
NThospital2018-09-21

Inquest into the death of Henry George Wilson aka Albert Wilson

77y · Male·sepsis due to retroperitoneal collection after biliary stent insertion on a back…

… 77-year-old Aboriginal man died from sepsis following a percutaneous transhepatic cholangiography (PTC) procedure that perforated his duodenum. Critical failures included: delayed diagnosis and treatment of peritonitis…

general surgeryradiologydiagnosticcommunicationpiperacillin/tazobactam
QLDPodcast2020-01-24

Willersdorf, Maria

87y · Female·Hypoxic-ischaemic encephalopathy secondary to cardiac arrest, with valvular hear…

An 87-year-old woman died following a CT-guided epidural injection at a private radiology clinic. Although she had undergone the procedure for spinal pain, the radiologist performed an epidural …

radiologypain medicinediagnosticproceduralbupivacaine
VIChospital2013-08-15

Finding into death of William John Colhoun

71y · Male·Multi organ failure due to post-operative bleeding following endoluminal thoraci…

…mber identified a renal artery tear with active haemorrhage—a previously unreported complication of this procedure. The tear was stented but profound blood loss led to multi-organ failure and death on 4 December. The co…

vascular surgeryradiologycommunication
VIChospital2022-02-28

Finding into death of H YR

77y · Female·Haemoperitoneum following cholecystectomy

A 77-year-old woman died from haemoperitoneum (intra-abdominal bleeding) three days after elective laparoscopic cholecystectomy. Bleeding from the left inferior epigastric artery was a recognised surgical complication bu…

general surgeryintensive carediagnosticdelaywarfarin
VIChospital2014-08-21

Finding into death of Neville Ross

65y · Male·Cardiac tamponade whilst undergoing CT-guided pericardiocentesis; perforation of…

…y died from cardiac tamponade during CT-guided pericardiocentesis. Key clinical issues: (1) Necessity of procedure was questionable—patient presented for routine echo before scheduled cardiology appointment, appeared cl…

cardiologyradiologydiagnosticprocedural
TAShospital2025-04-29

Coroner's Finding: de-identified OQ

41y · Female·frontal lobe ischaemic infarcts (strokes) caused by cerebral artery vasospasm co…

A 41-year-old woman died from frontal lobe ischaemic infarcts caused by cerebral vasospasm complicating subarachnoid haemorrhage from a ruptured aneurysm. She presented to multiple healthcare providers over five days wit…

emergency medicineneurosurgerydiagnosticcommunicationchlorpromazine
WAhospital2019-05-13

Inquest into the Death of Daniel Josef ADWENT

44y · Male·gunshot wound to abdomen

…Fiona Stanley Hospital involved extensive resuscitative efforts including thoracotomy, laparotomy, and interventional radiology. Critical clinical lessons include: delayed notification of consultant surgeons (general and…

emergency medicinegeneral surgerycommunicationdelay

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