Coroner's Finding: SORENSEN Ruth Bengta Maria

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

1. 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