Coronial
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TAShospital2019-04-16

Coroner's Finding: Hill, Phillip John

82y · Male·sepsis due to faecal peritonitis due to suture failure of bowel anastomosis foll…

An 82-year-old man died from sepsis due to faecal peritonitis following anastomotic breakdown after right hemi-colectomy for colon cancer. Sur…

colorectal surgerygeneral surgerydelayamiodarone
TAShospital2021-08-13

Coroner's Finding: Mrs M

Female·multi-organ failure

Mrs M died from multi-organ failure following recurrent intra-abdominal sepsis and surgical complications after endoscopic duodenal perforation in June 2019. During resection of a duode…

gastroenterologygeneral surgerydiagnostic
WAhospitalAugust 2023

Inquest into the Death of Justin DOBSON

46y · Male·sepsis following haemorrhoidectomy

46-year-old Justin Mark Dobson died from sepsis following a routine haemorrhoidectomy on 17 July 2019. He was discharged to the ward overnight but deterio…

general surgerycolorectal surgerydiagnosticcommunicationmetronidazole
VIChospital2023-02-22

Finding into death of Christine Ann Stephen

67y · Female·Intra-abdominal sepsis complicating an anastomotic leak following elective surge…

A 67-year-old woman died from intra-abdominal sepsis following an anastomotic leak from elective colorectal surgery to repair a vesico-colic fistula. The initi…

colorectal surgeryintensive carecommunicationdelaynoradrenaline
WAhospital2013-11-29

Inquest into the Death of Jones, Wilma Ray

75y · Female·Abdominal infection following surgery (repair of recurrent umbilical hernia) - s…

Wilma Ray Jones, 75, died of abdominal infection and sepsis following uncomplicated umbilical hernia repair. Post-mortem revealed ischaemic bowel with infarction, lik…

general surgeryanaesthesiadelaysystemephedrine
VIChospital2023-04-14

Finding into death of John Edward Hadland (Millar)

38y · Male·abdominal and chest sepsis complicating iatrogenic left pneumothorax and laparot…

…ar-old man with chromosome 1 short arm deletion syndrome, intellectual disability, and scoliosis died from sepsis following iatrogenic pneumothorax and emergency laparotomy for small bowel obstruction. He was admitted wi…

surgeryintensive careproceduralsystemmacrogol
TAShospital2018-03-26

Coroner's Finding: Russell; Patricia Joy

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

…ember, but this diagnosis was not made until 13 November—a six-day delay. The perforated oesophagus led to sepsis and empyema. The medical adviser found that the brown pleural fluid drained on 7 November should have prom…

surgeryanaesthesiadiagnosticdelay
WAhospital2013-01-17

Inquest into the Death of Mckay-Hall, Julienne Maria

46y · Female·Complications following cardiorespiratory arrest in association with an air embo…

…strectomy on 9 November 2007 had a staple misfire that was inadequately repaired. A leak developed causing sepsis, but recognition and management were dangerously delayed over 48 hours. On 11 November, the surgeon saw th…

general surgerybariatric surgerydiagnosticcommunicationmorphine
VIChospital2011-10-20

Finding into death of Andrew Westley

56y · Male·Cardiogenic shock, end stage ischemia due to chemo related cardiomyopathy, fulmi…

…nd. Post-operatively, he required prolonged ECMO, IABP, and biventricular assist devices but developed VRE sepsis, aspergillus infection, and multi-organ failure, dying 30 days post-transplant. Expert review found the de…

cardiothoracic surgerytransplant medicinedelayvancomycin
WAhospital2021-03-26

Inquest into the Death of Cyril CHURCHILL

68y · Male·surgical complications following laparoscopic cholecystectomy for cholecystitis,…

… developed profound hypotension. The treating team disagreed on whether the cause was internal bleeding or sepsis. A diagnosis of bleeding should have been reached earlier based on clinical signs, blood test results, and…

general surgeryanaesthesiadiagnosticcommunication
VIChospital2024-09-10

Finding into death of Christine Anne Flanagan

62y · Female·Complications arising from elective laparoscopic Hartmann's procedure for recurr…

…moid volvulus and ileus. Post-operatively uncomplicated initially, she deteriorated on day 3 with signs of sepsis (diaphoresis, distress, abdominal distension, mottling, poor perfusion), requiring ICU readmission and vas…

general surgeryintensive care
VIChospital2024-03-04

Finding into death of Frank Allen Hall-Bentick

69y · Male·Septic arthritis of the knee

… care. Despite optimal medical treatment, his condition rapidly deteriorated and he died from overwhelming sepsis. The clinical approach was appropriate given his comorbidities and documented preferences. No preventable …

intensive careemergency medicineantibiotics
NThospital2009-11-24

Inquest into the death of Maureen Caroline Thomson

58y · Female·acute peritonitis, which led to the development of acute septicaemia following a…

A 58-year-old woman died from acute peritonitis and sepsis following surgery for duodenal diverticulum. Initial elective surgery on 4 March 2008 was technically succ…

general surgerycolorectal surgeryenoxaparin
NSWhospital2019-12-19

Inquest into the death of Lesley ARNDELL

61y · Female·multi organ failure due to abdominal sepsis

Lesley Arndell, aged 61, died from multi-organ failure due to abdominal sepsis after undergoing a Whipple's procedure for pancreatic cancer. Key clinical lessons include: (1) patients w…

general surgeryintensive caremedicationcommunicationpiperacillin/tazobactam
SAhospital2010-12-30

Coroner's Finding: D'AGOSTINO Antonia

59y · Female·sepsis due to faecal peritonitis due to perforation of sigmoid colon complicatin…

A 59-year-old woman died from sepsis due to faecal peritonitis following a bowel perforation during laparoscopic oophorectomy for a benign ovar…

gynaecologygeneral surgerydiagnosticdelaypethidine
QLDhospital2016-02-22

Robertson, Elsie - Non-inquest findings

0y · Female·Hypoxic ischaemic encephalopathy due to intra-partum event and E. coli sepsis, s…

… weeks. She died 9 hours 43 minutes after birth from combined hypoxic-ischaemic encephalopathy and E. coli sepsis secondary to chorioamnionitis. Critical clinical lessons include: (1) confusion over twin nomenclature del…

obstetricsneonatologycommunicationsystemmagnesium sulphate
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 clinic…

general surgeryintensive carediagnosticdelayantibiotics
SAhospital2000-07-21

Coroner's Finding: HOWIESON Julie Ann

43y · Female·sepsis secondary to extensive acute peritonitis following perforation of small b…

43-year-old woman died from sepsis and necrotising fasciitis following small bowel perforation during laparoscopic tubal ligation. She was at…

gynaecologyanaesthesiadiagnosticdelay
NThospital2017-04-07

Inquest into the death of Gabby Wanambi

11y · Female·Acute Staphylococcal Septicaemia due to suppurative arthritis of the left ankle

…ailures included: no requirement for doctor assessment of ED patients after hours; inadequate staffing; no sepsis recognition protocol implementation despite a similar preventable death two years earlier; and poor clinic…

emergency medicineinfectious diseasesdiagnosticcommunicationparacetamol
WAhospital

Inquest into the Death of June Valerie LOBBAN

69y · Female·Intra-abdominal sepsis and shock with multi-organ failure following intestinal p…

A 69-year-old woman died from intra-abdominal sepsis and multi-organ failure following a perforated caecum that occurred after lumbar spine surgery. Post-opera…

neurosurgerygeneral surgerydiagnosticdelayfentanyl

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