Coronial
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Coroner's Finding: WHITE Kevin Charles

Deceased

Kevin Charles White

Demographics

57y, male

Date of death

2003-07-11

Finding date

2004-02-13

Cause of death

aspiration pneumonia secondary to small bowel obstruction

AI-generated summary

A 57-year-old man with chronic schizophrenia, intellectual disability, and history of bowel obstruction presented with faecal vomiting and signs of shock. He was appropriately transferred to hospital where small bowel obstruction and aspiration pneumonia were diagnosed. Conservative management with resuscitation was initially appropriate, but he rapidly deteriorated with septic shock and multi-organ failure. Surgical intervention was deemed futile given his unstable condition. The coroner found no criticism of his hospital treatment. Clinical lessons include: early recognition of aspiration risk in patients with dysphagia or altered mental status, appropriate escalation to ICU when clinically indicated, and multidisciplinary decision-making regarding futility of aggressive intervention in septic shock with multi-organ failure.

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

Specialties

emergency medicinesurgerygastroenterologyintensive careanaesthesiapsychiatry

Drugs involved

quetiapinepericyazinesodium valproateclonazepamticarcillin/clavulanateciprofloxacinadrenaline

Clinical conditions

small bowel obstructionaspiration pneumoniaseptic shockmulti-organ failurepulmonary oedemaschizophreniaborderline intellectual disabilitydysphagiacolostomy

Procedures

intubationmechanical ventilationcentral venous catheter insertionnasogastric suctionintravenous fluid resuscitation

Contributing factors

  • small bowel obstruction
  • aspiration of gastric contents
  • septic shock
  • multi-organ failure
  • patient's difficulty tolerating examination and treatment due to mental incapacity
  • delayed IV access attempts at initial assessment
Full text

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