25 results
68y · Female·haemopericardium resulting from perforation of the pericardial sac during laparo…
Mrs Christine Flynn, aged 68, died from haemopericardium and pericardial tamponade following laparoscopic hiatus hernia repair. A 2mm perforation of the pericardial sac occurred during surgery, likely from mesh tacks pla…
74y · Male·small intestinal ischaemia caused by aortic atherosclerosis
A 74-year-old man presented to hospital with abdominal pain following a fall. He developed hypotension, fever, tachycardia, and elevated inflammatory markers consistent with sepsis within hours of admission. Despite clea…
73y · Male·sepsis due to ischemic gut due to occlusion of the superior mesenteric artery
A 73-year-old man presented with acute severe abdominal pain caused by superior mesenteric artery (SMA) occlusion. Initial CT angiogram at 12:30am was reported as normal; the SMA occlusion was not identified until 4:45am…
73y · Female·sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopi…
A 73-year-old woman died from sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopic revision of gastric bypass surgery. She had complex medical history with multiple post-operative complicatio…
Male·Multiple injuries including thoracic vertebral fracture and blunt trauma of thor…
Anthony John Flight died from multiple injuries sustained in a motor vehicle collision on the Bass Highway, Tasmania. He was struck from behind by a heavy vehicle while lawfully stationary awaiting a right turn. Despite …
65y · Female·decompensated liver failure
Ms Revell, a 65-year-old with Child Pugh Class C cirrhosis secondary to 20 years of heavy alcohol use and hepatitis C, was admitted following an intoxicated fall causing an olecranon fracture. Post-operatively, she devel…
71y · Male·sepsis caused by mediastinal empyema (abscess) which complicated perforation of …
Terence Carroll, 71, died from sepsis and mediastinal empyema following oesophageal perforation during rigid oesophagoscopy for stricture dilation. Critical failures included: CT scan showing suspicious oesophageal thick…
77y · Male·shock due to bowel ischaemia following massive blood loss due to bleeding of the…
Anthony George Bennett, a 77-year-old man with significant comorbidities including ischaemic heart disease, atrial fibrillation, peripheral vascular disease, and end-stage kidney disease, died from shock due to bowel isc…
67y · Male·acute gastrointestinal haemorrhage complicating peptic ulcer of the duodenum wit…
A 67-year-old man died from acute gastrointestinal haemorrhage from a duodenal ulcer following complex post-operative complications from laparoscopic Hartmann's procedure for diverticulitis. Key clinical lessons: (1) Ear…
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 duodenal adenoma, perforation occurred r…
80y · Male·acute myocardial ischaemia due to coronary atherosclerosis
Mr Wade, aged 80, died from acute myocardial infarction following knee surgery. On postoperative day 3, he developed chest symptoms, elevated troponin, and hypoxia. An ECG was performed showing acute anterior myocardial …
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…
66y · Male·hepatic failure, intrahepatic sepsis and intrahepatic haematoma secondary to com…
William Ernest Pears died from hepatic failure, intrahepatic sepsis and haematoma following a laparoscopic cholecystectomy in 2012. During surgery for gallstone disease, the right hepatic duct was damaged and repaired, b…
76y · Male·Sepsis due to pulmonary valve endocarditis and cardiac abscess due to Staphyloco…
A 76-year-old man died from sepsis caused by Staphylococcus aureus endocarditis and cardiac abscess. An intravenous cannula inserted during day surgery on 29 November 2018 was not removed before discharge, despite hospit…
71y · Female·pneumonia following cervical spine fracture sustained in motor vehicle collision
Julie Anne Holmes, aged 71, died of pneumonia following a cervical spine fracture sustained in a motor vehicle accident that was not diagnosed during her hospital admission. Critical clinical lessons include: (1) paramed…
58y · Female·Ischaemic small bowel due to bowel obstruction most likely due to a combination …
Mrs Fulham, aged 58, died from ischaemic small bowel due to obstruction from adhesions and Crohn's disease recurrence. On 22 November, she presented to GP with two weeks of diarrhoea, vomiting, nausea, and abdominal pain…
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. Surgery was appropriate and proceeded without incident. Five days post-operativel…
57y · Male·sepsis and multiple organ failure secondary to aspiration pneumonia
Timothy Fenton, a 57-year-old intellectually disabled man on antiepileptic medications, developed a small bowel ileus after presenting with vomiting and diarrhoea. Following emergency laparotomy, his nasogastric tube was…
53y · Female·sepsis and multiple organ failure attributable to infarction/necrosis of small b…
A 53-year-old woman with Type II diabetes, obesity, and Korsakoff dementia presented with acute severe abdominal pain from superior mesenteric artery (SMA) thrombosis at 3:00 AM on 19 August. Despite elevated lactate, me…
76y · Male·multiple organ failure due to large volume aspiration of gastric contents during…
Maurice Nancarrow, 76, died from multiple organ failure following aspiration of gastric contents during anaesthetic induction for cystoscopy on 15 August 2015. He had undergone colorectal surgery on 30 July with complica…
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