72 results
48y · Male·Pulmonary thromboembolism
Guy Christian Mason, 48, died from a saddle pulmonary embolism on 17 September 2023, three days after discharge from patellar tendon repair surgery. He had sustained a significant knee injury with multiple ligament ruptu…
66y · Female·Acute oesophagitis complicated by gastrointestinal haemorrhage
A 66-year-old woman with cerebral palsy, dysphagia, and chronic reflux oesophagitis presented with acute gastrointestinal bleeding while in supported disability accommodation. She was treated conservatively with IV proto…
72y · Male·Complications of suspected upper gastrointestinal tract haemorrhage, hospital ac…
A 72-year-old man with metastatic squamous cell lung cancer and multiple serious comorbidities was admitted to Ballarat Hospital in July 2024 with lethargy, fatigue, and rapid atrial fibrillation. Due to medication chart…
88y · Female·Infective complications arising from injuries sustained in low speed motor vehic…
Barbara Cameron, 88, died on 5 January 2026 from infective complications of injuries sustained in a low-speed motor vehicle accident on 29 October 2025. She was exiting her parked vehicle at a shopping centre car park in…
87y · Female·Oesophageal perforation following an elective oesophageal dilatation, secondary …
87-year-old Helen Mahlis died from oesophageal perforation following an elective balloon dilation procedure at Epworth Richmond for treatment of achalasia. The coroner identified two contributing factors: use of a 35mm b…
86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall
James Reilly, 86, fell at home on 8 September 2024 sustaining rib fractures that caused a fatal left haemothorax. Paramedics attended but he declined transfer. When facial droop developed, he was admitted with presumed t…
59y · Female·Complications of a pseudo-obstruction on a background of previous anterior resec…
Julie Anne White, 59, died from complications of pseudo-obstruction following previous sigmoid volvulus resection. She had intellectual disability, dementia, schizophrenia, depression, and chronic bowel dysmotility. Admi…
72y · Male·Complications of a gastroduodenal perforation (palliated) in the setting of mult…
William Anthony Daniel, a 72-year-old SDA resident with intellectual impairment and multiple comorbidities, presented to Box Hill Hospital on 7 November 2024 with postural hypotension, nausea, vomiting and abdominal pain…
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…
85y · Male·Liver ischaemia and portal vein thrombosis complicating emergency cholecystectom…
Kenneth James Anderson, an 85-year-old man with intellectual disability and multiple comorbidities including diabetes, pancreatitis, and gallstones, died following emergency cholecystectomy for acute cholecystitis with M…
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…
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…
40y · Male·Aspiration pneumonia
Alexander Cameron, a 40-year-old man with complex neurodevelopmental, neurological and psychiatric disorders including epilepsy, autism, and previous neuroleptic malignant syndrome (NMS), died from aspiration pneumonia f…
65y · Male·Middle cerebral artery stroke in a man with multiple medical co-morbidities
Winfried Medenbach, a 65-year-old man with tuberous sclerosis, severe intellectual disability, epilepsy, and history of bowel complications, died from a middle cerebral artery stroke. He had been admitted to hospital in …
62y · Female·Complications arising from elective laparoscopic Hartmann's procedure for recurr…
Christine Flanagan, a 62-year-old woman with severe disabilities and gastroparesis, died from complications following an elective laparoscopic Hartmann's procedure for recurrent sigmoid volvulus and ileus. Post-operative…
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…
57y · Male·Aspiration pneumonia complicating large bowel volvulus in a man with chronic dys…
Andrew John Martin, aged 57 with cerebral palsy and chronic dysphagia, was admitted with large bowel volvulus managed conservatively per advance directives. After clinical improvement, he was transferred to palliative ca…
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…
74y · Male·Intra-abdominal haemorrhage complicating elective umbilical hernia repair
A 74-year-old man with significant cardiac history (atrial fibrillation, dilated cardiomyopathy, pacemaker) underwent elective umbilical hernia repair. Intraoperatively, unexpected ascites was discovered and partially dr…
66y · Male·Ruptured abdominal aortic aneurysm
A 66-year-old man presented to the Emergency Department with left-sided abdominal pain on 14 July 2021. After waiting over 6 hours in a crowded ED with restricted access to treatment spaces, he left without medical asses…
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