78y · Female·multi-organ failure due to haemorrhage into the abdomen, pelvis and retroperiton…
…abdominal and retroperitoneal haemorrhage following extensive anterior and posterior lumbar spinal fusion surgery. The patient had multiple comorbidities, previous spinal surgery with persistent pain, osteoporosis, and …
77y · Male·shock due to bowel ischaemia following massive blood loss due to bleeding of the…
…ood loss from the left internal iliac artery after elective abdominal aortic aneurysm repair. The initial surgery was technically difficult but performed uneventfully. Post-operative bleeding required transfusion and IC…
59y · Female·sepsis due to faecal peritonitis due to perforation of sigmoid colon complicatin…
…ring laparoscopic oophorectomy for a benign ovarian cyst. The perforation was repaired during the initial surgery, but the repair failed. The patient deteriorated at home and was readmitted. The primary issue was delay …
86y · Male·Acute Myocardial Ischaemia in an Elderly Man with Valvular and Ischaemic Heart D…
Henry Edwin Kerr, 86, died of acute myocardial ischaemia following left inguinal hernia surgery at Esperance District Hospital. He had significant cardiac history including valvular disease, ischaemic …
38y · Female·Unascertained
Nilofer Nezami, a 38-year-old Victorian resident, died on 7 January 2019 following cosmetic surgery in Iran. She underwent multiple procedures including eye, breast, arm and abdominal surgery. Post-operati…
42y · Male·Hypoxic ischaemic brain injury secondary to cardiac arrest caused by massive pul…
…xaparin 40mg daily and TED stockings. The PE occurred intraoperatively during planned definitive fixation surgery 11 days post-injury. The coroner found the medical care provided at both Royal Melbourne Hospital and Bru…
51y · Male·cerebral fat embolism due to surgery for multiple traumatic injuries sustained i…
… found no issues with medical care and noted that fat embolism is an unpredictable complication of trauma surgery. The collision itself resulted from driver distraction rather than mechanical or environmental factors.
86y · Male·Complications post laparoscopic cholecystectomy
…rty-two hours after admission. Severe bleeding from hepatic arterial branches required conversion to open surgery, CPR, and massive transfusion. Myocardial infarction occurred intraoperatively in a patient with underlyi…
61y · Male·hospital acquired pneumonia complicating aorto-femoral bypass surgery for periph…
…peripheral vascular disease, alcohol dependence, and heavy smoking history underwent aorto-femoral bypass surgery. Post-operatively he developed hospital-acquired pneumonia, delirium from alcohol withdrawal, and hepatic…
57y · Female·Pulmonary thromboembolism
Ann-Maree Manno, 57, died from pulmonary thromboembolism 8 days after laparoscopic gastric band surgery. She had significant risk factors: obesity (BMI 37.9), history of unprovoked DVT in 2007 and 2016, and re…
56y · Male·Pulmonary embolism with deep vein thrombosis an antecedent cause; coronary arter…
…edical history of hypercholesterolaemia, hypertension, obesity, and depression, underwent elective dental surgery on 28 October 2015 to remove four wisdom teeth and resect a cyst. He was discharged the same day as plann…
13y · Female·Complex congenital heart disease (operated) and sepsis
…tricular septal defect and major aorta-pulmonary collateral arteries), died from sepsis following cardiac surgery. She was born in March 2010 and underwent emergency cardiac surgery in February 2011 to connect pulmonary…
61y · Female·Diffuse alveolar damage in a woman with restrictive lung disease following catar…
…old woman with severe restrictive lung disease, obesity, cardiac failure, and diabetes underwent cataract surgery at a private day surgery centre on 13 August 2018. She was unable to lie flat and became hypoxic (oxygen …
16y · Female·obstructed breathing and heart arrhythmia secondary to severe obstructive sleep …
…riginal girl with severe obstructive sleep apnoea died unexpectedly in her home one week before scheduled surgery. She had been symptomatic since age 13, but surgery was delayed for four years due to multiple system fai…
Female·Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perfor…
Two elderly women died following vaginal prolapse surgery performed by the same surgeon, Dr O., with similar mechanisms: bowel perforation leading to peritonitis a…
59y · Male·Ruptured atherosclerotic abdominal aortic aneurysm (operated)
…te appropriate initial assessment identifying the AAA as requiring urgent repair, surgical staff deferred surgery twice—once at 3.20am and again at noon—delaying intervention for 34 hours. The patient was haemodynamical…
50y · Male·myocardial infarction caused by coronary atherosclerosis
…ated umbilical hernia. He died in custody at Alice Springs Hospital shortly after emergency hernia repair surgery. Despite pre-existing conditions making him unfit for surgery (10% survival chance), he consented after f…
68y · Male·pulmonary thromboembolism in the setting of recent surgery
A 68-year-old man died from pulmonary thromboembolism following revisional gastric bypass surgery. He developed multiple post-operative complications including fever, elevated inflammatory markers, and a…
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 successful, but the p…
3y · Male·cerebral oedema which caused coning at the base of the brain, caused by post-ope…
…r-old boy died from cerebral oedema caused by post-operative hyponatraemia following scoliosis correction surgery. The operation was successful, but severe hyponatraemia developed in the early hours of 24 April 1988, ca…
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