Deceased
Dawn Ruth Roach
Demographics
45y, female
Date of death
1998-05-22
Finding date
2001-05-04
Cause of death
Multi-organ failure due to septicaemia and peritonitis due to faecal leakage from the large intestine following the failure of a loop colostomy created to deal with a leaking anastomosis following surgery for removal of a carcinoma of the distal sigmoid colon
AI-generated summary
A 45-year-old woman died from multi-organ failure following failure of a loop colostomy created for management of an anastomotic leak after bowel cancer surgery. The initial anastomotic leak (1.5 cm) was contained and reasonably managed conservatively. However, the colostomy performed on 5 May 1998 was poorly constructed: sited in a deep body fold under tension, with an unsuture bridge, and lacking abscess drainage. These deficiencies led to predictable failure. Despite early nursing warning signs (darkening stoma from 6 May), the patient was inappropriately discharged on 11 May 1998 while unwell and unable to manage the stoma. Within one day, the bridge dislodged, the bowel retracted, and catastrophic peritonitis ensued. The clinical lesson is that colostomy complications identified early (days 1-3 post-op) should trigger prompt revision rather than conservative observation, particularly when there are objective signs of compromise. Discharge decisions require senior surgical oversight, not junior trainee discretion, when patients remain unwell.
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Specialties
Error types
Clinical conditions
Procedures
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Paul Eugene Anker, a 53-year-old prisoner, died from metastatic rectal carcinoma at the Queen Elizabeth Hospital. He had been appropriately diagnosed with bowel cancer in 2016 whilst in custody and underwent surgery, che…
9y · Female·peritonitis due to perforated small bowel due to blunt abdominal trauma
Nine-year-old Leila Baartse-Harkin died from peritonitis due to a perforated small bowel sustained when she fell from a swing. Despite three medical encounters within 36 hours, the perforation was never diagnosed. At a r…
71y · Male·acute pyelonephritis with contributing ischaemic heart disease
A 71-year-old male prisoner died from acute pyelonephritis with contributing ischaemic heart disease at Flinders Medical Centre. He had advanced metastatic gastric cancer diagnosed in February 2011 after presenting with …
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