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VIChospital2026-02-10

Finding into death of David Ronald Thompson

64y · Male·Complications of advanced rectal carcinoma

David Ronald Thompson, a 64-year-old man with severe intellectual disability and complex medical needs, died from complications of advanced rectal carcinoma. He resided in specialist disability accommodation and had been…

colorectal surgeryoncology
VIChospital2026-01-23

Finding into death of MD

82y · Male·Complications of large bowel obstruction in a man with diverticular disease and …

An 82-year-old man died from complications of large bowel obstruction secondary to a sigmoid mass while incarcerated at Port Phillip Prison. He presented with abdominal pain and vomiting following a fall, and imaging con…

general surgerycolorectal surgerywarfarin
SA2025-08-28

Coroner's Finding: RJR

65y · Male·metastatic rectal cancer with extensive lung metastases

A 65-year-old man died from metastatic rectal cancer with extensive lung metastases while serving a prison sentence. He had presented with rectal bleeding symptoms since 2011 and returned a positive faecal occult blood t…

colorectal surgeryoncologyapixaban
VIChospital2025-08-04

Finding into death of Winifred Jean Carpenter

82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…

Winifred Carpenter, 82, died 11 days after a right hemicolectomy for colon cancer from peritonitis due to anastomotic leak. Critical failures occurred on discharge day (10 March 2023): clinicians did not recognize her de…

general surgerycolorectal surgerydiagnosticcommunication
QLDhospital2025-06-20

Inquest into the death of Christopher Glen Essery

74y · Male·Sepsis secondary to fistulating Crohn's disease and post-surgery complications f…

Christopher Essery, a 74-year-old man with complex fistulating Crohn's disease, died from sepsis following surgery on 24 January 2019. He was transferred to Princess Alexandra Hospital (PAH) on 31 August 2018 for special…

colorectal surgerygastroenterologysystemcommunication
VIChospital2024-05-21

Finding into death of Murray Noel Haggar

65y · Male·Complications following a malignant bowel obstruction in a man with multiple com…

Murray Noel Haggar, a 65-year-old man with cerebral palsy and intellectual disability living in specialist disability accommodation, died from complications of malignant bowel obstruction. He presented with chronic const…

colorectal surgerypalliative care
NSWhospital2024-01-29

Inquest into the death of Sean Montgomery

70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia

70-year-old Sean Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner identified multiple significant failing…

cardiothoracic surgerygeneral surgerydiagnosticcommunicationmorphine
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 deteriorated significantly from 11:00 am on 18 July, showing hypotension,…

general surgerycolorectal surgerydiagnosticcommunicationmetronidazole
VIChospital2023-05-30

Finding into death of Thelma Annie Ogilvy

90y · Female·abdominal sepsis complicating perforated diverticular abscess of the sigmoid col…

Thelma Annie Ogilvy, a 90-year-old woman from rural Victoria, died from abdominal sepsis complicating a perforated diverticular abscess. She presented with bowel obstruction requiring laparotomy on 21 October 2019, was d…

general surgerycolorectal surgeryapixaban
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 initial surgery on 1 November 2017 was appropriately performed, an…

colorectal surgeryintensive carecommunicationdelaynoradrenaline
VIChospital2022-11-29

Finding into death of Paul Desmond Smith

58y · Male·complications of large bowel pseudo-obstruction

Paul Desmond Smith, aged 58, died from complications of large bowel pseudo-obstruction following discharge from hospital after inadequate assessment. He had presented to the ED with lower abdominal pain and severe faecal…

general surgerycolorectal surgerydiagnosticcommunicationmacrogol
VIChospital2022-05-09

Finding into death of Robert Albert Burns

75y · Male·Multiorgan dysfunction syndrome complicating anastomotic leak following hemicole…

A 75-year-old man died from multiorgan dysfunction following an anastomotic leak after hemicolectomy for caecal adenocarcinoma. Initial post-operative recovery appeared normal, but he deteriorated from day 3 onwards. The…

colorectal surgeryintensive carediagnosticdelay
NSWhospital2022-04-05

Inquest into the death of Ronald TURNER

81y · Male·Consequences of bowel obstruction

Ronald Turner, an 81-year-old man in lawful custody, died from consequences of bowel obstruction with aspiration pneumonia. He had a history of recurrent sigmoid volvulus despite previous surgery. On 22 January 2020, he …

colorectal surgerygeriatric medicine
WAhospital2021-09-14

Inquest into the Death of Jeremy Michael SCOTT

63y · Male·metastatic rectal carcinoma

Jeremy Scott, a 63-year-old prisoner, died from metastatic rectal carcinoma on 3 July 2017. From 2015 onwards, he reported rectal and anal symptoms including pain, bleeding, and palpable masses, which were repeatedly att…

general surgerycolorectal surgerydiagnosticcommunication
NSWhospital2021-05-25

Inquest into the death of Melvin LYNCH

72y · Male·Complications of subtotal colectomy for diffuse polyposis and invasive adenocarc…

Melvin Lynch, aged 72, died in custody at Prince of Wales Hospital on 9 December 2019, nine days after elective subtotal colectomy for bowel cancer. Post-operatively, he developed complications including pleural effusion…

colorectal surgerygeneral surgery
TAShospital2021-02-03

Coroner's Finding: Boon Alison Kim

51y · Female·peritoneal sepsis with multiple organ failure due to perforation of bowel by for…

A 51-year-old woman with intellectual 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 vag…

general surgerycolorectal surgerydiagnostic
VIChospital2021-01-29

Finding into death of Robert Gerard Dimattina

58y · Male·Aspiration pneumonia complicating small bowel obstruction in the setting of rece…

A 58-year-old man died from aspiration pneumonia complicating small bowel obstruction six days after elective laparoscopic subtotal colectomy for colorectal cancer. On post-operative day 6, he developed fever, tachycardi…

colorectal surgeryintensive care
VIChospital2021-01-28

Finding into death of MrsL

52y · Female·Neutropenic sepsis leading to multi-organ failure due to capecitabine toxicity

Mrs L, a 52-year-old woman with T2N0M0 rectal cancer, died from neutropenic sepsis and multi-organ failure secondary to severe capecitabine toxicity on 31 October 2018. She commenced neoadjuvant chemotherapy with capecit…

oncologyradiation oncologydiagnosticdelaycapecitabine
SAhospital2020-12-18

Coroner's Finding: ANKER Paul Eugene

53y · Male·metastatic carcinoma of the rectum (operated)

Paul Eugene Anker, a 53-year-old prisoner, died from metastatic rectal carcinoma at the Queen Elizabeth Hospital. He had been appropriately diagnosed with bowel cancer in 2016 whilst in custody and underwent surgery, che…

oncologycolorectal surgerydexamethasone
WAhospital2020-08-13

Inquest into the Death of Susan Jessica Elsie WINDIE

22y · Female·bowel obstruction due to faecal impaction

Susan Windie, a 22-year-old with rare congenital abnormalities affecting bowel function, died from bowel obstruction due to faecal impaction complicated by abdominal compartment syndrome. She presented to Carnarvon Hospi…

gastroenterologygeneral practicecommunicationsystemfleet enema

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