Coronial
NThospital

Inquest into the death of David Fensom

Deceased

David Colin Fensom

Demographics

67y, male

Date of death

2010-10-19

Finding date

2018-09-21

Cause of death

multi-organ failure due to septic shock consequent on faecal peritonitis due to perforated ischaemic bowel

AI-generated summary

David Fensom, 67, underwent elective fundoplication for hiatus hernia and reflux on 21 September 2010. He developed severe right-sided abdominal pain post-operatively. A laparoscopy on 8 October misinterpreted findings and missed ischaemic bowel—a critical diagnostic error. The expert review identified a 48-hour delay before appropriate laparotomy on 10 October revealed perforated ischaemic bowel with faecal peritonitis and pseudomonal sepsis. While subsequent ICU management was appropriate, the delayed diagnosis of a surgical emergency in a patient with known adhesion history proved fatal. Clinicians should maintain high suspicion for mesenteric ischaemia when severe abdominal pain is disproportionate to examination findings, particularly in patients with prior abdominal surgery. Communication with family was also severely deficient, with no explanation of death provided until eight years later.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general surgeryemergency medicineintensive careanaesthesia

Error types

diagnosticcommunicationdelaysystem

Drugs involved

fentanylmorphineglyceryl trinitrate

Clinical conditions

hiatus herniagastro-oesophageal reflux diseasesmall bowel obstructionpostoperative adhesionsmesenteric ischaemiaischaemic bowel necrosisbowel perforationfaecal peritonitispseudomonal sepsismulti-organ failureseptic shock

Procedures

laparoscopic 360 degree nissen fundoplicationlaparoscopy (diagnostic, 8 october)laparotomyhemicolectomysmall bowel resectionileostomy formationmucous fistula creationintubationrenal replacement therapy

Contributing factors

  • missed diagnosis of ischaemic bowel at laparoscopy on 8 October 2010
  • misinterpretation of laparoscopic findings
  • inadequate clinical suspicion for mesenteric ischaemia despite known adhesion history
  • 48-hour delay before appropriate laparotomy
  • surgeon's cognitive bias—focusing on fundoplication complications rather than ischaemic bowel
  • failure to escalate to theatre when deterioration became apparent on 9 October
  • poor communication with family throughout admission and after death
  • death not reported to Coroner

Coroner's recommendations

  1. Top End Health Service ensure that medical staff have all necessary induction and training in relation to appropriate communication with patients and families about symptoms, pain, prognosis, risk of procedures and limits of care
  2. Top End Health Service speak to families after the death of a loved one and ensure that the family have been afforded proper communication, open disclosure and their reasonable needs are being met
  3. Top End Health Service ensure that all deaths of patients that are reportable pursuant to the Coroners Act are reported in accordance with the law
Full text
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Source and disclaimer

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