Coronial

24 results for intra-operative haemorrhage

WAhospital- 27 May 2014

Inquest into the Death of Julissa Teresa GILBERT

57y · Female·Intra-abdominal Haemorrhage following Appendectomy, with contributing factor of …

…g on friable tissues with limited visibility. Post-operatively, mesenteric tears caused intra-abdominal haemorrhage (1600mls), but this was misdiagnosed as septic shock. The locum doctor managing post-operative care fai…

anaesthesiasurgerydiagnosticcommunicationaramine
VIChospital2022-10-18

Finding into death of Kenneth Ernest O'Brien

74y · Male·Intra-abdominal haemorrhage complicating elective umbilical hernia repair

…developed hypotension and was transferred to ICU. The coroner found that post-operative intra-abdominal haemorrhage was not recognised early enough. Critical factors included: over-reliance on a single haemoglobin resul…

general surgeryanaesthesiadiagnosticcommunicationapixaban
VIChospital2014-08-27

Finding into death of Robert Vivian Hawkins

55y · Male·Multi-system failure complicating intra-operative haemorrhage due to inadvertent…

Robert Vivian Hawkins, a 55-year-old man, died from multi-system failure following inadvertent ligation of the superior mesenteric artery (SMA) during laparoscopic nephrectomy for renal cell carcinoma. Dr L. misidentifie…

urologygeneral surgerydiagnosticprocedural
VIChome2014-04-17

Finding into death of Rodney Mark Moore

45y · Male·Sudden death of unascertained cause, occurring eight days after laparoscopic cho…

… The coroner concluded the cause of death was unascertained, occurring in the setting of post-operative haemorrhage. No fault was found with the surgeon's conduct or the nursing care provided. The clinical lesson is tha…

general surgeryanaesthesiaesomeprazole
QLDhospital2009-03-20

Woolgar, Shealah Ann

83y · Female·Haemorrhage due to mitral valve disease (surgically repaired); specifically haem…

An 83-year-old woman died from haemorrhage following mitral and tricuspid valve repair surgery. During intra-operative testing of the repaired mit…

cardiothoracic surgeryanaesthesiaproceduralwarfarin
WAhospital2018-06-14

Inquest into the Death of Anne RZEPCZYNSKI

59y · Female·complications of intra-abdominal sepsis, including multi-organ failure and bowel…

59-year-old woman died from intra-abdominal sepsis, multi-organ failure and bowel perforation following median hepatectomy for cholangiocarcinoma. Key clinical issues included: surgical delays of 20 days between stent in…

general surgeryintensive carediagnosticdelayantibiotics
SAhospital2004-11-18

Coroner's Finding: PEDDEY Ross Dudley

63y · Male·pneumonia complicating anoxic brain injury, due to post-operative haemorrhage as…

A 63-year-old man died from pneumonia complicating anoxic brain injury following a post-operative haemorrhage from the inferior epigastric artery during ileostomy closure surgery. The critical failure was a 2.5-ho…

colorectal surgerygeneral surgerydiagnosticdelaywarfarin
WAhospital- 27 May 2014

Inquest into the Death of Brian John DAVIES

57y · Male·Multiple Organ Failure and Intra-Abdominal Haemorrhage following Cholecystectomy

…ransferred to ICU at a tertiary hospital on day 2 but died from multi-organ failure and intra-abdominal haemorrhage secondary to coagulopathy. Key learning: very high-risk patients with extensive comorbidities may benef…

surgeryanaesthesiasystemdelaymorphine
VIChospital2022-03-15

Finding into death of Ann Leah Jones

87y · Female·Pulmonary artery rupture complicating pulmonary artery catheter insertion in a w…

…pulmonary artery injury. Despite intubation and resuscitation attempts, she developed massive pulmonary haemorrhage, hypoxia, and cardiac arrest. An intra-aortic balloon pump inserted during resuscitation caused seconda…

cardiothoracic surgeryanaesthesiaproceduralsystemfentanyl
VIChome2013-11-27

Finding into death of Andrew Gilmore

17y · Male·intra-abdominal haemorrhage complicating partial pancreatectomy for traumatic pa…

…despite recurrent post-operative pain in a complex case. Andrew collapsed and died from intra-abdominal haemorrhage (1400ml) from likely splenic artery breakdown due to pancreatic juice erosion—a rare complication at da…

general surgeryemergency medicinecommunicationdelayoxycodone
QLDhospital2007-12-07

Burgen, Deborah Denise

49y · Female·Intra-abdominal haemorrhage, septic and haemorrhagic shock as a result of a lapa…

Deborah Burgen died from intra-abdominal haemorrhage complicated by septic shock following delayed emergency surgery for bowel obstruction. She attended the…

emergency medicinesurgerydiagnosticdelayparacetamol/codeine
VIChospital2012-12-14

Finding into death of Jeanette Brown

66y · Female·Multi-organ failure associated with haemorrhage and sepsis following cholecystec…

Mrs Jeanette Brown, 66, died from multi-organ failure following post-operative haemorrhage after elective laparoscopic cholecystectomy. Arterial clips applied to the cystic artery during surgery…

general surgeryanaesthesiaproceduralcommunicationamlodipine
VIChospital2022-02-28

Finding into death of H YR

77y · Female·Haemoperitoneum following cholecystectomy

…er MET call), inadequate fluid and blood resuscitation (only 1 unit PRBC over 2 hours despite confirmed haemorrhage), failure to check coagulation status until 7:45 pm despite therapeutic anticoagulation, lack of urinar…

general surgeryintensive carediagnosticdelaywarfarin
TAShospital2018-12-05

Coroner's Finding: Suckling, James William

72y · Male·hypovolemic shock due to haemoperitoneum following surgical repair of an abdomin…

A 72-year-old man died from hypovolemic shock due to intra-abdominal haemorrhage following Spigelian hernia repair. Post-operatively he presented with hypotension, bradycardia and swea…

surgeryemergency medicinediagnosticcommunicationmetaraminol
VIChome2013-05-07

Finding into death of JOVO VRANJESEVIC

57y · Male·thalamic haemorrhage with ventricular extension

A 57-year-old man with hypertension and atrial fibrillation suffered a massive thalamic haemorrhage while at home and was declared brain dead at hospital. His organs were donated to three recipients who …

transplant medicineintensive care
VIChospital2026-01-23

Finding into death of Dorothy Anne Simm

74y · Female·Non traumatic intracerebral haemorrhage with further deterioration post medical …

Dorothy Simm, a 74-year-old woman, died from intracerebral haemorrhage with post-operative deterioration following participation in the EVACUATE trial at Monash Medical Centr…

neurosurgeryneurology
NThospital2004-01-16

Inquest into the death of Souzana Afianos

41y · Female·secondary haemorrhage following gastric banding surgery

A 41-year-old enrolled nurse died from secondary haemorrhage eight days after laparoscopic gastric banding surgery in Darwin. She attended ED on 18 February with po…

general surgeryemergency medicinecommunicationsystemparacetamol/codeine
WAhospital2015-08-12

Inquest into the Death of Helen Christine MacFARLAINE

52y · Female·intracerebral haemorrhage in a lady with underlying cerebrovascular disease and …

… despite elevated BP readings and preceding day's complications. She suffered catastrophic intracranial haemorrhage the next morning, attributed to likely hyperperfusion syndrome. Key failures included inadequate docume…

neurosurgeryintensive carecommunicationsystemaspirin
VIChospital2014-08-29

Finding into death of Noella Rae Clohesy

62y · Female·Multi-organ failure due to lacerated abdominal aorta complicating laparoscopic b…

A 62-year-old woman died from multi-organ failure caused by a lacerated abdominal aorta sustained during elective laparoscopic gastric band surgery in 2006. The aorta was cut by a Visiport trocar blade at the start of th…

general surgeryanaesthesiaproceduralcommunication
QLDhospital2017-10-17

SWK - Non inquest findings

78y · Female·multi-organ failure due to haemorrhage into the abdomen, pelvis and retroperiton…

…ar-old Jehovah's Witness died from multi-organ failure secondary to intra-abdominal and retroperitoneal haemorrhage following extensive anterior and posterior lumbar spinal fusion surgery. The patient had multiple comor…

spinal surgeryorthopaedic surgeryproceduraldiagnosticaramine

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