Coronial

18 results for open laparotomy

TAShospital2020-04-03

Coroner's Finding: Pears, William Ernest

66y · Male·hepatic failure, intrahepatic sepsis and intrahepatic haematoma secondary to com…

…ears. The coroner found that operators encountering laparoscopic difficulties should consider converting to open surgery or abandoning the procedure. The undetected left hepatic duct injury appears to have been the root …

surgerygeneral surgerydiagnosticprocedural
VIChospital2022-02-28

Finding into death of H YR

77y · Female·Haemoperitoneum following cholecystectomy

…uld have survived with earlier diagnosis and aggressive resuscitation, though angioembolisation rather than open laparotomy was performed.

general surgeryintensive carediagnosticdelaywarfarin
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 …

…aemic bowel—a critical diagnostic error. The expert review identified a 48-hour delay before appropriate laparotomy on 10 October revealed perforated ischaemic bowel with faecal peritonitis and pseudomonal sepsis. While …

general surgeryemergency medicinediagnosticcommunicationfentanyl
NSWhospital2023-03-09

Inquest into the death of William Edmunds

79y · Male·complications of peritonitis

…nd did not review the patient daily post-operatively, missing opportunities for early detection. Inadequate open disclosure by Dr S. meant the patient and family did not understand the nature of the error. By the time th…

general surgeryintensive careproceduraldiagnosticmorphine
SAhospital2016-09-29

Coroner's Finding: MCSHANE Robert Ian

66y · Male·Multi-system failure and ischaemic gut after left nephrectomy complicated by mas…

…ever deploy staplers without complete visualisation of contents in the jaws, consider earlier conversion to open surgery when laparoscopic bleeding cannot be controlled, and ensure adequate surgical assistance and senior…

urologyvascular surgeryproceduralsurgical judgment
WAhospital2023-10-18

Inquest into the Death of Corazon Contreras KEELEY

71y · Female·complications of metastatic endometrial carcinoma, treated palliatively

…mic failures included inadequate result notification, lack of consultant handover during leave, and delayed open disclosure to the family.

gynaecologyoncologydiagnosticcommunication
VIChospital2025-10-15

Finding into death of Gary William Bruce

71y · Male·Complications following a right hepatic artery injury following an open cholecys…

…h myelofibrosis and prior abdominal surgery died from complications of a right hepatic artery injury during open cholecystectomy for acute cholecystitis. The operative decision was reasonable and the intraoperative injur…

general surgeryanaesthesiacommunicationsystem
SAhospital2011-08-05

Coroner's Finding: LEONARD Emily Ruth and HILLMAN Glenys Anne

Female·Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perfor…

…came apparent 6 days post-discharge, resulting in multi-organ failure and death. Mrs Hillman (67) underwent open surgery on 28 May 2009; a small bowel perforation was identified and repaired intraoperatively, but the rep…

gynaecologyintensive carediagnosticproceduralheparin
VIChospital2016-04-14

Finding into death of Kelly Maree Richards

29y · Female·Exsanguination post tubal ligation procedure

…tery occurred during the procedure, likely during trochar insertion. The surgeon appropriately converted to open laparotomy and attempted haemorrhage control via packing, consistent with surgical guidelines. However, Mrs…

general surgerygynaecologyproceduralcommunicationpacked red blood cells
SAhospital2025-06-12

Coroner's Finding: Salter, Kathleen Ethel

76y · Female·multi-organ failure and sepsis due to complications of cholecystectomy

A 76-year-old woman died from multi-organ failure and sepsis following a laparoscopic cholecystectomy at a rural hospital. During surgery, the surgeon became misoriented in the inflamed surgical field and divided the com…

general surgeryanaesthesiadiagnosticproceduralapixaban
QLDhospital2007-08-10

Tang, Shannon Sheng Wen

21y · Male·multi-organ failure due to septicaemia of mixed respiratory (bronchopneumonia) a…

Shannon Tang, a 21-year-old from Singapore with severe obesity (BMI 52) and multiple comorbidities including sleep apnoea, underwent elective laparoscopic gastric bypass surgery performed by Dr F.. He died on day 7 post-…

bariatric surgerygeneral surgerycommunicationdiagnosticvancomycin
TASaged care2018-01-29

Coroner's Finding: Ball, Betty Irene

67y · Female·perforated sigmoid volvulus with peritonitis upon a background of spinocerebella…

Betty Irene Ball, aged 67, died from perforated sigmoid volvulus with peritonitis on 2 February 2016. She had spinocerebellar ataxia and was resident in aged care. She developed constipation from 15 January 2016, but med…

general practiceemergency medicinedelaysystemparacetamol
WAhospital2001-04-12

Inquest into the Death of Margaret Patton Brooks

43y · Female·Haemorrhage Associated with Penetrations of the Aorta

…nting activation of the trocar's safety shield. Despite immediate recognition of bleeding and conversion to open surgery with vascular repair, the deceased died from traumatic blood loss and organ ischaemia. The coroner …

general surgeryanaesthesiaprocedural
VIChospital2022-08-19

Finding into death of Ruth Ann McKenna

62y · Female·Hypovolaemic and cardiogenic shock (hysterectomy) in the context of cardiomegaly…

A 62-year-old woman with significant comorbidities (cirrhosis, cardiomegaly, thrombocytopenia, chronic kidney disease, COPD) died from hypovolaemic and cardiogenic shock during elective total laparos…

gynaecologyanaesthesiadiagnosticsystemmetaraminol
QLDhospital2012-12-06

McNaught, Judith

69y · Female·Septic shock due to biliary peritonitis as a consequence of laparoscopic cholecy…

A 69-year-old woman died of septic shock following bile leak complications after laparoscopic cholecystectomy. Critical failures included: (1) inappropriate transfer to low-dependency unit on post-op day 1 despite consul…

surgeryanaesthesiadiagnosticmedicationmorphine
QLDhospital2011-06-24

(C) a 15 month old child

1y · Male·Complication of burns and trauma to the mesenteric artery

A 15-month-old child died from complications of severe scalding burns (55% of body) sustained when left unsupervised in a bath of hot water (65°C) for 10-15 minutes, combined with traumatic mesenteric artery tears of unk…

paediatricsplastic and reconstructive surgerycommunicationsystemrisperidone
NSWhospital2019-03-22

Inquest into the death of Patrick THOMAS

52y · Male·Intestinal failure/sepsis arising from venous ischemia as a result of superior m…

Patrick Thomas, a 52-year-old man, died from intestinal failure and sepsis following an accidental division of the superior mesenteric vein (SMV) during laparoscopic surgery for colon cancer at Kareena Private Hospital o…

colorectal surgeryintensive carecommunicationsystem
VIChospital2023-10-30

Finding into death of BCT

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

BCT was a 2-year-old Aboriginal child with complex needs from a genetic disorder (CAMTA1 mutation) who died from hypoxic-ischaemic encephalopathy following sepsis related to bowel perforation after a percutaneous endosco…

gastroenterologyradiologydiagnosticcommunicationceftriaxone

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