Deceased
Michael Sutherland
Demographics
male
Date of death
2006-03-03
Finding date
2011-07-14
Cause of death
Faecal peritonitis due to perforated diverticulum
AI-generated summary
Michael Sutherland presented to Bega Hospital Emergency Department on 2 March 2006 with severe abdominal pain from diverticulitis with bowel perforation. Dr B., the attending Career Medical Officer, formed an unfounded belief the patient was drug-seeking and withheld adequate analgesia and further investigation. Despite afternoon clinical deterioration—including tachycardia of 170 bpm, hyperventilation, elevated blood glucose—Dr B. discharged him without diagnosis. He died the next day of faecal peritonitis. The coroner found multiple preventable errors: premature diagnostic closure, grossly inadequate pain relief, failure to escalate or perform CT imaging, and failure to act on clear signs of serious illness. Cognitive biases (stereotyping, anchoring, availability heuristic) led to diagnostic failure. A CT scan would likely have revealed the diagnosis. The coroner identified failures in nursing advocacy, hierarchical communication, and absence of CT scanning at the regional hospital.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
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