Coroner's Finding: Cheesman, Trevor Allan

70y · Male·complications arising from craniofacial resection and orbital exenteration for right sinonasal adenocarcinoma

A 70-year-old man died following complex craniofacial resection and orbital exenteration for right sinonasal adenocarcinoma. Multiple surgical complications occurred including carotid artery injury, cerebral infarction, CSF leak, and infection. He developed delirium postoperatively necessitating Mental Health Act orders. The coroner found the ITOs were appropriately imposed and there was a delay in the first ITO review due to notification system failures, subsequently rectified. No failings by medical staff contributed to death. The prognosis was guarded given extensive surgery, complications, and comorbidities. The death resulted from surgical complications in the context of high-risk surgery for an aggressive malignancy.