QLDhospital

Tranby, James Errol

Deceased

James Errol Tranby

Demographics

64y, male

Coroner

Barnes

Date of death

2008-12-17

Finding date

2011-06-09

Cause of death

necrotising fasciitis precipitated by a fishbone perforating his rectum, leading to abdominal sepsis and peritonitis

AI-generated summary

James Tranby, a 64-year-old Indigenous diabetic prisoner, presented with a fish bone lodged in his rectum on 3 December 2008. Following removal on 5 December, he developed progressive sepsis leading to necrotising fasciitis. Critical delays occurred: surgery was delayed 32 hours (justified by surgical scheduling), and more significantly, when he returned on 8 December with markedly elevated white cell count and radiographic evidence of intra-abdominal pathology, a first-year registrar (Dr C.) attributed symptoms to urinary retention and referred to urology rather than urgently consulting his supervisor. The coroner found this referral delayed laparotomy by ~24 hours and was an error of judgment. While the coroner noted concerns about the adequacy of initial surgical exploration, no adverse finding was formally made against the supervising surgeon. Necrotising fasciitis was definitively identified only on 12 December during the second operation. Despite six subsequent operations, Mr Tranby died on 17 December. The coroner concluded Mr Tranby's chances would have improved with earlier surgical exploration on 8-9 December, though by 12-13 December the infection was too advanced for better outcome.

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

Specialties

general surgerycolorectal surgeryurologyemergency medicineintensive carecorrectional health

Error types

diagnosticdelaycommunication

Drugs involved

insulinmorphinetramadolparacetamolbroad-spectrum antibioticsvasopressin

Clinical conditions

necrotising fasciitisperforated rectumabdominal sepsisperitonitisparalytic ileusacute urinary retentiondiabetes mellituscoronary atherosclerosisemphysema

Procedures

foreign body removal (fish bone)rectal examinationlaparoscopylaparotomyabdominal debridementcolostomy formationurinary catheterization

Contributing factors

32-hour delay in removing fish bone due to surgical scheduling pressures
failure to urgently escalate or consult supervisor when patient returned 8 December with signs of intra-abdominal infection
misdiagnosis of urinary tract infection; inappropriate referral to urology that delayed surgical exploration by approximately 24 hours
first-year registrar (Dr C.) did not seek urgent review of abnormal x-rays and elevated white cell count despite patient's risk factors (diabetes, recent anorectal surgery)
inadequate depth of surgical exploration during initial laparotomy on 10 December regarding identification of all infection sites
patient's diabetes increased susceptibility to infection
systemic delays in hospital information sharing with correctional centre regarding medical emergencies

Coroner's recommendations

Queensland Corrective Services review its policy governing notification of prisoners' nominated contact persons when prisoners undergo medical procedures, to ensure that family members are notified in a timely manner in cases involving unexpected outcomes of relatively minor procedures or progressive deterioration, avoiding situations where families are not informed until a prisoner is in critical condition or deceased

Full text

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Source and disclaimer

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