Deceased
Margaret Isabel Horsington
Demographics
83y, female
Coroner
Rinaudo
Date of death
2004-11-23
Finding date
2007-05-04
Cause of death
cardiac arrest from severe triple vessel coronary artery disease complicated by large bowel obstruction from rectal carcinoma with lung compression from raised diaphragm
AI-generated summary
Margaret Isabel Horsington, aged 83, died from cardiac arrest secondary to severe coronary artery disease, complicated by large bowel obstruction from rectal carcinoma. She presented to Roma Hospital with constipation and was diagnosed appropriately, but clinical management deteriorated. Fleet enema was administered despite prior failed bowel clearance attempts, worsening abdominal distension and compressing her diaphragm, causing respiratory compromise and cardiac stress. The coroner identified systemic failures: inadequate senior medical supervision, failure to reassess the treatment plan when initial interventions failed, and incomplete radiological assessment. Dr G. lacked experience to challenge Dr B.'s distant decision-making. Key clinical lessons: senior clinician presence is essential for complex cases in rural settings; treatment plans must be reassessed when ineffective; and systemic staffing is critical to patient safety. The coroner found no individual culpability but identified systemic problems subsequently addressed.
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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