Deceased
Ben James Witham
Demographics
17y, male
Date of death
2011-05-24
Finding date
2012-10-29
Cause of death
Multi-organ failure with terminal fungal sepsis (Aspergillus) on a background of acute lymphoblastic leukaemia; gastric perforation was a contributing cause
AI-generated summary
Ben Witham, a 17-year-old with acute lymphoblastic leukaemia, died from multi-organ failure with terminal fungal sepsis. The critical issue identified was a substantial delay in investigating acute severe abdominal pain on 13 May 2011. Despite classic peritoneal signs noted at 9:30 pm (generalised tenderness, guarding, rebound tenderness), no imaging or surgical review occurred until 14 May, resulting in approximately 17 hours before laparotomy for gastric perforation. The consultant oncologist's assessment relied on a junior doctor's description rather than direct examination; further investigations including overnight x-rays and scans were available but not ordered. This delay allowed peritonitis and bacterial infection to develop, contributing significantly to death. The coroner found the standard of care during this period inadequate. An initial positive arsenic test result proved to be contamination/error; no public health risk existed.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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