Coroner's Finding: SORENSEN Ruth Bengta Maria
Deceased
Ruth Bengta Maria Sorensen
Demographics
69y, female
Date of death
2002-07-24
Finding date
2005-06-03
Cause of death
faecal peritonitis due to small bowel obstruction and perforation due to peritoneal adhesions
AI-generated summary
A 69-year-old woman presented to the Emergency Department with abdominal pain and vomiting. The doctor did not take adequate history, perform thorough physical examination, or order basic investigations including blood tests or abdominal X-ray. She was discharged after 2 hours 40 minutes without diagnosis. She deteriorated rapidly and died at home the next morning from faecal peritonitis due to small bowel obstruction and perforation from peritoneal adhesions. The coroner found the standard of care was seriously inadequate. Critical lessons: elderly patients with undiagnosed abdominal pain require low threshold for admission, basic investigations (FBC, urea/electrolytes, abdominal X-ray), careful history including surgical history, attention to abnormal vital signs, and high index of suspicion to avoid premature diagnostic closure with 'gastroenteritis' diagnosis.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- inadequate history taking regarding nature, severity and characteristics of abdominal pain
- failure to document previous abdominal surgery despite it being recorded in triage
- failure to note abnormal vital signs (raised temperature, raised pulse rate)
- failure to examine for surgical scars on abdomen
- failure to assess bowel sounds
- failure to order basic diagnostic tests (FBC, urea/electrolytes, liver function tests, amylase/lipase, urine test)
- failure to order plain abdominal X-ray
- inadequate observation period prior to discharge
- premature diagnostic closure with 'gastroenteritis' diagnosis without adequate supporting evidence
- failure to admit elderly patient with undiagnosed abdominal pain for observation
- discharge decision made 2 hours 40 minutes after initial consultation without full assessment
- failure to recognise significance of undiagnosed abdominal pain in elderly patient
- patient's stoicism may have minimised apparent severity of symptoms
Coroner's recommendations
- Directors of Emergency Departments in all hospitals in South Australia re-evaluate their policies and procedures applying to patients presenting with abdominal pain, and in particular elderly patients with a history of abdominal surgery, in light of the criticisms made by Associate Professor Brown and the academic articles he has produced
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