Deceased
Mark Andrew Butler
Demographics
49y, male
Date of death
2009-07-04
Finding date
2012-11-15
Cause of death
pneumonia, hypoxic brain injury and cardiac arrest
AI-generated summary
49-year-old male with chronic cannabis dependence and depression developed post-surgical delirium following emergency anterior resection for perforated diverticulum. He became acutely agitated and paranoid, was detained under mental health order, and shackled to bed. After freeing himself and being restrained by security staff, he suffered cardiac arrest with hypoxic brain injury and died. Contributing factors included failure to recognise cannabis withdrawal contributing to delirium, use of anticholinergic olanzapine potentially worsening confusion, and shackling potentially worsening paranoia. Expert opinion noted clinical errors occurred but no clear causal link to fatal outcome. Death attributed to pneumonia, hypoxic brain injury and cardiac arrest on background of coronary atherosclerosis and ischaemic heart disease.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
9y · Female·peritonitis due to perforated small bowel due to blunt abdominal trauma
Nine-year-old Leila Baartse-Harkin died from peritonitis due to a perforated small bowel sustained when she fell from a swing. Despite three medical encounters within 36 hours, the perforation was never diagnosed. At a r…
Female·Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perfor…
Two elderly women died following vaginal prolapse surgery performed by the same surgeon, Dr Onuma, with similar mechanisms: bowel perforation leading to peritonitis and sepsis. Mrs Leonard (77) underwent laparoscopic sur…
59y · Female·sepsis due to faecal peritonitis due to perforation of sigmoid colon complicatin…
A 59-year-old woman died from sepsis due to faecal peritonitis following a bowel perforation during laparoscopic oophorectomy for a benign ovarian cyst. The perforation was repaired during the initial surgery, but the re…
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