Coroner's Finding: Joan Dennison
Deceased
Joan Dennison
Demographics
78y, female
Date of death
2007-11-18
Finding date
2010-12-21
Cause of death
sepsis and aspiration with metabolic dysfunction as a result of mechanical small bowel obstruction
AI-generated summary
Joan Dennison, aged 78, was discharged from Shellharbour Hospital emergency department on 16 November 2007 with a misdiagnosis of constipation, despite clinical and imaging features diagnostic of small bowel obstruction caused by abdominal adhesions from previous surgery. She had presented with vomiting, anorexia, weight loss, and x-ray findings showing multiple air-fluid levels and significantly dilated loops of bowel. The ED doctor consulted the surgical registrar at Wollongong Hospital by telephone, but critical failures occurred: incomplete communication of imaging findings, failure to review the radiologist's formal report, and acceptance of an inappropriate treatment plan (enema). The surgical registrar failed to view available x-rays despite direct access through the PACS system and asked insufficient clarifying questions about her symptoms. She collapsed at home days later and died from sepsis with aspiration complications. The coroner found the death preventable and made recommendations for assertiveness training and improved clinical communication protocols (ISBAR).
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Misdiagnosis of small bowel obstruction as constipation
- Failure to view x-ray images by surgical registrar despite access to PACS system
- Inadequate communication of x-ray findings between doctors
- Failure to recognize significance of x-ray findings (multiple air-fluid levels and dilated bowel loops)
- Failure to review radiologist's formal report before discharge
- Inappropriate treatment plan (enema for small bowel obstruction)
- Inadequate clinical questioning by surgical registrar regarding symptoms
- Lack of assertiveness by referring doctor in challenging senior clinician's opinion
- Failure to admit patient for observation despite differential diagnosis of bowel obstruction
- Absence of morbidity and mortality meetings at hospital until 2008
Coroner's recommendations
- Southern Hospitals Network to include graded assertiveness training as part of the establishment of the Simulation Centre at Wollongong Hospital
- ISBAR principles to continue to be emphasized in the training of all medical staff in the Southern Hospitals Network
- Superseded telephone consultation checklist for medical officers to be incorporated into the training of medical officers in the Southern Hospitals Network as part of the ISBAR program
- The principle that responsibility and authority for the transfer of patients from one hospital to another remains with the referring clinician in the sending hospital to be emphasized to all medical staff and those involved in the patient transfer process in the Southern Hospitals Network
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —