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.
Clinical conditions
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
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