57y · Male·Small bowel ischaemia (operated) with incarcerated umbilical hernia
…, presented to hospital with acute abdominal pain and was found to have incarcerated umbilical hernia with small bowel ischaemia requiring emergency surgery. He died from multiple organ failure despite resection of four…
68y · Male·Pneumonia due to bowel obstruction due to follicular lymphoma
…icular lymphoma (treated with chemotherapy), was admitted to St Vincent's Hospital on 7 December 2007 with small bowel obstruction. He underwent laparotomy and ileocaecal resection on 27 December 2007. Postoperatively h…
74y · Male·Small bowel obstruction due to extensive intra-abdominal adhesions
Timothy Funder, a 74-year-old man with schizophrenia, chronic obstructive pulmonary disease, and previous small bowel obstruction, died from small bowel obstruction due to extensive intra-abdominal adhesions. He presen…
60y · Male·metastatic atrial sarcomatoid tumour
…l metastases were discovered in April 2020 whilst in prison. He received appropriate palliative surgical resection and oncological care, with frank discussions about his poor prognosis and incurable condition. Advanced …
27y · Male·multiple organ failure due to the consequences of multiple gunshot wounds to the…
…t 2008 when he presented with vomiting and abdominal pain, which led to emergency surgery revealing a rare small bowel volvulus requiring total bowel resection. Expert evidence established that this volvulus was excepti…
91y · Male·Complications following cardiac arrest in the setting of anaesthetic induction d…
…ium died from complications following anaphylaxis to rocuronium during anaesthetic induction for emergency small bowel obstruction surgery. His GP records documented allergy to both suxamethonium and vecuronium (a non-d…
46y · Male·metastatic malignant melanoma
A 46-year-old man with metastatic malignant melanoma died in custody at a hospice. He was extradited from New South Wales to South Australia in April 2009 while undergoing cancer treatment. There was an 8-week delay befo…
70y · Female·Hypoxic/Ischaemic Encephalopathy consequent upon Cardiorespiratory Arrest and Co…
…l carcinoma on 2 April 2008 at Royal Hospital for Women. The complex surgery was complicated by iatrogenic small bowel perforations. Post-operatively, wound dehiscence and bowel obstruction developed, requiring return t…
53y · Female·sepsis and multiple organ failure attributable to infarction/necrosis of small b…
…ng surgery locally. Surgery began at 7:06 PM on 20 August (40 hours after onset). Despite thrombectomy and bowel resection, the patient developed extensive small bowel necrosis and died on 27 August from sepsis and mult…
51y · Female·peritoneal sepsis with multiple organ failure due to perforation of bowel by for…
…l disability and schizoaffective disorder died from peritoneal sepsis and multiple organ failure caused by bowel perforation from a wooden stick. The stick entered her body via her vaginal canal. She presented with abdo…
67y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …
…d abdominal pain post-operatively. A laparoscopy on 8 October misinterpreted findings and missed ischaemic bowel—a critical diagnostic error. The expert review identified a 48-hour delay before appropriate laparotomy on…
79y · Male·complications of peritonitis
A 79-year-old man with multiple comorbidities presented with a perforated bowel requiring emergency Hartmann's procedure. The operating surgeon, Dr L.-Ming Schmidt, made a catastrophic s…
65y · Female·Aspiration pneumonia following emergency laparotomy for incarcerated umbilical h…
A 65-year-old woman with intellectual disability, congenital blindness, diabetes, and epilepsy presented with an incarcerated umbilical hernia requiring emergency surgery. Post-operative aspiration occurred in recovery w…
68y · Male·infarction of the small and large bowel due to superior mesenteric artery thromb…
…a. By the time mesenteric ischaemia was suspected the following morning and imaging arranged, irreversible bowel necrosis had occurred. The coroner found that earlier recognition of mesenteric ischaemia as a differentia…
Female·Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perfor…
…men died following vaginal prolapse surgery performed by the same surgeon, Dr O., with similar mechanisms: bowel perforation leading to peritonitis and sepsis. Mrs Leonard (77) underwent laparoscopic surgery on 30 Octob…
75y · Female·large volume aspiration following right hemicolectomy for adenocarcinoma of the …
A 75-year-old woman with a 20-month history of iron deficiency anaemia was not investigated for its cause by her general practitioner despite clear clinical signs of deterioration. The coroner found this fell 'grossly sh…
60y · Female·Multiple organ failure following hemorrhage from penetration of the femoral arte…
…er 2010. An Angio-Seal device was used to close the puncture site. She was discharged on 22 October with a small hematoma. By 25 October, she presented to her GP with a dramatically enlarged, extremely painful hematoma.…
54y · Male·Bowel ischaemia resulting from acute thrombosis of superior mesenteric artery an…
Anthony Barrett died from bowel ischaemia caused by acute thrombosis of his superior mesenteric artery and coeliac artery stents post-oper…
71y · Male·Complications following a right hepatic artery injury following an open cholecys…
A 71-year-old man with 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…
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