Coroner's Finding: MOUSTAKOS Erini
Deceased
Erini Moustakos
Demographics
53y, female
Date of death
2001-09-17
Finding date
2003-03-14
Cause of death
infarction of the transverse colon due to mesenteric/retroperitoneal haemorrhage and incisional abdominal hernia in the setting of anticoagulation
AI-generated summary
A 53-year-old woman with schizophrenia died from transverse colon infarction secondary to mesenteric/retroperitoneal haemorrhage and incisional abdominal hernia during anticoagulation therapy. She was admitted to hospital with delirium; an organic cause (UTI) was found and treated. A pulmonary embolism was diagnosed and anticoagulation commenced. She developed abdominal pain and imaging suggested small bowel obstruction managed conservatively. Warfarin levels became dangerously high (6-8 September) leading to internal haemorrhage. The coroner found no diagnostic error: strangulated colon was not clinically evident, and emergency surgery in her confused, non-compliant state would likely have been fatal. Clinical team performance was commended. Key issues identified were communication gaps with family and missing medication records, though these did not affect the cause of death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
Clinical conditions
Contributing factors
- over-anticoagulation with warfarin (6-8 September 2001)
- dangerously high warfarin levels on 6 and 8 September
- pre-existing large incisional abdominal hernia
- pulmonary embolism (diagnosed 24 August 2001)
- small bowel obstruction
- patient confusion and non-compliance limiting clinical assessment
- obesity complicating surgical assessment
Full text
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