Coroner's Finding: WILMAN Joyce Millicent (aka Bracegirdle)
Deceased
Joyce Millicent Wilman
Demographics
62y, female
Date of death
2007-02-09
Finding date
2009-11-25
Cause of death
gastric necrosis and perforation due to strangulated diaphragmatic hernia
AI-generated summary
Joyce Wilman, 62, died from gastric necrosis and perforation due to strangulated para-oesophageal hernia whilst detained under Mental Health Act at Queen Elizabeth Hospital. She presented with vomiting and abdominal pain from 5-8 February 2007. Imaging on 6 February revealed the hernia with recommendation for clinical correlation, but no gastroenterological review occurred despite psychiatric trainee requesting it. Critical delays in specialist consultation meant surgical expertise was unavailable for 24+ hours. Expert evidence indicated that timely gastroenterology review on 7 February would likely have enabled diagnosis and meaningful surgical intervention to prevent death. Coroner found insufficient effort to secure specialist review and delayed delivery of final X-ray reports contributed to preventable death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- failure to obtain timely gastroenterology review
- delayed delivery of final X-ray report
- inadequate clinical correlation between radiological findings and symptoms
- unreliable communication system for specialist referrals
- insufficient persistence in paging specialist staff
- lack of awareness of hernia complication among psychiatric staff
Coroner's recommendations
- Queen Elizabeth Hospital develop and implement measures to ensure X-ray reports prepared by radiological registrars and specialists are prepared and made available in timely manner so abnormalities are acted upon before patient health is compromised
- Minister for Health cause review of X-ray report delivery in all public hospitals to ensure final X-ray reports are delivered in timely manner
- Written interim X-ray reports be kept as part of patient clinical file to provide record of what was known before final report delivery
- Queen Elizabeth Hospital take necessary steps to ensure when specialist medical or surgical review is directed or recommended that it be sought and provided with necessary degree of urgency and by most efficient means of communication available
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