Coroner's Finding: SANDS Celia Laurel
Deceased
Celia Laurel Ivy Sands
Demographics
82y, female
Date of death
1999-05-15
Finding date
2001-09-07
Cause of death
peritonitis due to a perforated viscus (proximal jejunum) resulting from motor vehicle accident
AI-generated summary
An 82-year-old woman suffered a motor vehicle accident causing blunt abdominal trauma. Despite initial clinical assessment appearing adequate, a perforated jejunum with developing peritonitis was not diagnosed until early morning of day 2, when she had deteriorated significantly. Key clinical lessons: (1) In blunt abdominal trauma, CT scanning should be considered early even with initially reassuring signs, particularly in elderly patients who may be stoic about symptoms; (2) Objective deterioration—decreased urine output, persistent pain beyond 24 hours, fever—should trigger escalation and senior review; (3) Critical vital sign changes including acidosis, hypoxia, and tachycardia in the early morning of day 2 indicated sepsis/peritonitis requiring immediate surgical consultation. The senior surgeon should have been notified when these objective findings emerged, though prognosis remained grave given established peritonitis and her age.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- failure to order CT scan on day 1 or early day 2 despite clinical suspicion
- delayed recognition of objective deterioration (decreased urine output, persistent pain, fever)
- delayed escalation to senior surgeon despite emerging signs of peritonitis in early morning of day 2
- night medical officer did not call consultant surgeon when vital signs deteriorated and acidosis developed
- delay in surgical intervention until late morning of day 2
Coroner's recommendations
- The Chief Executive Officer of Lyell McEwin Hospital should review the hospital's arrangements for night cover to ensure there are no barriers to communication with consultants.
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