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Coroner's Finding: Cannell, Peter Tasman

Deceased

Peter Tasman Cannell

Demographics

48y, male

Date of death

2019-09-05

Finding date

2021-11-25

Cause of death

Multi-organ failure from acute gastrointestinal haemorrhage associated with oesophageal varices on a background of liver cirrhosis

AI-generated summary

Peter Tasman Cannell, aged 48, died in Flinders Medical Centre from multi-organ failure due to acute gastrointestinal haemorrhage from oesophageal varices on a background of liver cirrhosis. He had a medical history of hepatitis C, cirrhosis, thrombocytopenia, and anaemia. Clinical warning signs were present: he reported blood in stool in 2016 and black stools in 2018, both concerning for gastrointestinal bleeding. In August 2019, his haemoglobin had dropped from 142 to 118 over three months, prompting specialist referral. On 2 September, he suffered massive variceal bleeding while imprisoned, with approximately 1.5 litres blood loss. The coroner found no deficiency in care. Early recognition of bleeding risk and expedited gastrointestinal evaluation (particularly given his refusals of colonoscopy) may have enabled preventive intervention such as variceal banding or beta-blocker prophylaxis before catastrophic haemorrhage occurred.

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

Specialties

gastroenterologyhepatologyintensive careemergency medicinecorrectional health

Clinical conditions

liver cirrhosishepatitis Coesophageal varicesacute gastrointestinal haemorrhageiron deficiency anaemiathrombocytopeniamulti-organ failureshock

Procedures

colonoscopyabdominal ultrasoundupper gastroscopyvariceal bandingblood transfusiondialysis

Contributing factors

  • Liver cirrhosis from hepatitis C
  • Oesophageal varices
  • Previous gastrointestinal bleeding episodes (2016, 2018) with patient refusal of repeat colonoscopy
  • Declining haemoglobin levels prior to acute event
  • Massive acute variceal haemorrhage with shock
  • Patient non-compliance with recommended investigations
Full text

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