Coronial

21 results for oesophageal perforation

TAShospital2024-12-09

Coroner's Finding: Brand, Robin William

62y · Male·Mediastinitis due to perforated oesophagus, with severe emphysema as a contribut…

A 62-year-old man with severe emphysema and chronic oesophageal stricture died from mediastinitis secondary to perforated oesophagus. He had undergone 46 oesophageal d…

gastroenterologyemergency medicine
TAShospital2018-03-26

Coroner's Finding: Russell; Patricia Joy

74y · Female·empyema/sepsis complicating oesophageal perforation following a complicated elec…

… leak from the colon anastomosis requiring surgical repair. Critically, she also suffered a spontaneous oesophageal perforation (Boerhaave syndrome) likely on 6-7 November, but this diagnosis was not made until 13 Novem…

surgeryanaesthesiadiagnosticdelay
VICmental health2025-11-11

Finding into death of Graziano Birgi

86y · Male·Oesophageal perforation

…old man with treatment-resistant paranoid schizophrenia residing in a secure psychiatric unit died from oesophageal perforation. He experienced two unwitnessed falls on 20 October 2024 and declined post-fall medical ass…

psychiatrygeriatric medicine
TAShospital2022-10-26

Coroner's Finding: Carroll, Terence John

71y · Male·sepsis caused by mediastinal empyema (abscess) which complicated perforation of …

Terence Carroll, 71, died from sepsis and mediastinal empyema following oesophageal perforation during rigid oesophagoscopy for stricture dilation. Critical failures included: CT scan sho…

ENT surgerygeneral surgerycommunicationdiagnostic
VIChospital2026-06-12

Finding into death of Helen Mahlis

87y · Female·Oesophageal perforation following an elective oesophageal dilatation, secondary …

87-year-old Helen Mahlis died from oesophageal perforation following an elective balloon dilation procedure at Epworth Richmond for treatment of achal…

gastroenterologygeneral surgeryproceduraldiagnostic
VIChospital2023-03-31

Finding into death of Callie Griffiths-I'Anson

2y · Female·perforated oesophagus secondary to complications of treatment of oesophageal inj…

…he underwent an oesophagoscopy and dilation procedure performed to standard, but suffered an iatrogenic perforation of the oesophagus during or immediately following the procedure. The perforation went undetected despit…

paediatric surgeryanaesthesiacommunicationsystemmidazolam
SAhospital2022-06-10

Coroner's Finding: Bertram, Kerry Anne

42y · Female·multiorgan failure complicating hyperthermia and metabolic acidosis following su…

…tensive care management including haemodiafiltration, ethanol infusion, and treatment of complications (oesophageal perforation, mediastinitis, acute kidney injury, septic shock), she developed cerebral oedema with hern…

intensive carepsychiatryalcohol
SAhospital2003-05-08

Coroner's Finding: PRATT Shirley May

66y · Female·acute necrotising haemorrhagic mediastinitis

…ive gastroscopy at Kapunda Hospital. During the procedure she heaved, and blood was noted at the gastro-oesophageal junction. She was discharged the same afternoon with pain, only to return within hours with pleuritic c…

surgerygeneral surgerycommunicationsystemfentanyl
TAShospital2024-07-25

Coroner's Finding: Briffa, Gennette Anne

73y · Female·sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopi…

A 73-year-old woman died from sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopic revision of gastric bypass surgery. She had complex medical …

bariatric surgerygeneral surgerydiagnosticdelayapixaban
VIChospital2025-11-28

Finding into death of Virginia Catherine Harris

60y · Female·Non-operative management of ruptured oesophagus (palliated)

Virginia Harris, a 60-year-old woman with epilepsy and intellectual disability living in supported accommodation, presented with abdominal pain on 18 March 2023. Initial examination by her GP showed mild tenderness that …

general practiceemergency medicine
ACThospital2019-11-22

Inquest into death of JAMIE LAWRENCE MITCHELL

36y · Male·Septicaemia and cerebral artery air embolism, due to complications related to cl…

…l artery air embolism complicating radiofrequency ablation for atrial fibrillation. He developed an atrioesophageal fistula after cardiac ablation at Royal Adelaide Hospital, which was not detected pre-discharge. Presen…

cardiologycardiothoracic surgerydiagnosticdelay
SAhospital2009-11-25

Coroner's Finding: WILMAN Joyce Millicent (aka Bracegirdle)

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 …

psychiatrygastroenterologydiagnosticcommunication
VIChospital2011-11-29

Finding into death of Ralph James McCracken

65y · Male·complications of end stage chronic obstructive pulmonary disease

…mia requiring femoral embolectomy, subsequently developed compartment syndrome, pancolitis with sigmoid perforation requiring subtotal colectomy, and experienced recurrent infections including pseudomonas chest infectio…

vascular surgerycolorectal surgeryantibiotics
NSWhospital2018-04-26

Inquest into the death of Margaret Ann Pegum

67y · Female·Sepsis as a result of gastric perforation

Margaret Pegum, aged 67, died from sepsis following gastric perforation after an intragastric balloon (IGB) procedure for weight loss. She had undergone fundoplication for hia…

gastroenterologybariatric surgerydiagnosticcommunication
VIChospital2019-04-04

Finding into death of Isabella Estelle Rees

1y · Female·Gastrointestinal haemorrhage due to aorto-oesophageal fistula caused by lodged b…

…atochezia. A button battery lodged in her oesophagus caused progressive caustic injury leading to aorto-oesophageal fistula and fatal gastrointestinal haemorrhage. Parents repeatedly expressed concerns about foreign bod…

emergency medicinepaediatricsdiagnosticcommunicationondansetron
QLDhospital2015-11-03

Steer, Summer Alice

4y · Female·Haemorrhage due to aorto-oesophageal fistula caused by ingestion of a button bat…

A 4-year-old girl died from aorto-oesophageal fistula and haemorrhage caused by a lithium button battery lodged in her oesophagus for at least 3 days…

general practiceemergency medicinediagnosticcommunicationmetronidazole/flagyl
VIChospital2013-08-13

Finding into death of Thelma Katherine Holt

79y · Female·pneumonia in the setting of acute peritonitis due to perforated stomach (operate…

…ifying patency. By 1 February, her condition deteriorated, and emergency surgery revealed large gastric perforation with peritonitis. She died 14 March 2009 from pneumonia in the setting of acute peritonitis. Key preven…

gastroenterologygeneral surgerydiagnosticproceduralsertraline
VIChospital2023-10-30

Finding into death of BCT

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

…rder (CAMTA1 mutation) who died from hypoxic-ischaemic encephalopathy following sepsis related to bowel perforation after a percutaneous endoscopic gastrojejunostomy (PEG-J) procedure. Critical failures included: delay …

gastroenterologyradiologydiagnosticcommunicationceftriaxone
QLDhome2005

Shaw, Lillian Margaret

67y · Female·perforated gastric ulcer; morphine toxicity also made a significant contribution

…d at home—a large dose inappropriate for undiagnosed abdominal pain and potentially masking symptoms of perforation. The patient died 2.5 hours later from a perforated gastric ulcer, with morphine toxicity significantly…

general practicegastroenterologydiagnosticmedicationtramadol
NThospital2018-09-21

Inquest into the death of David Fensom

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 laparoscopy on 8 October misinterpreted findings a…

general surgeryemergency medicinediagnosticcommunicationfentanyl

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