Coroner's Finding: McManus, Pamela
Deceased
Pamela McManus
Demographics
75y, female
Date of death
2012-09-15
Finding date
2015-11-27
Cause of death
large volume aspiration following right hemicolectomy for adenocarcinoma of the colon
AI-generated summary
A 75-year-old woman with a 20-month history of iron deficiency anaemia was not investigated for its cause by her general practitioner despite clear clinical signs of deterioration. The coroner found this fell 'grossly short' of the standard of care expected. When eventually diagnosed with colonic cancer at the hepatic flexure, she underwent right hemicolectomy but died from aspiration two days post-operatively. Medical adviser Dr B. opined that prompt investigation of iron deficiency anaemia would have enabled earlier cancer diagnosis when the patient was in better health, potentially offering 50% five-year survival compared to her actual outcome. The case highlights the critical importance of investigating the cause of iron deficiency anaemia, particularly in older patients with systemic symptoms, rather than simply treating the anaemia itself.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- failure to investigate iron deficiency anaemia for 20 months in primary care
- failure to pursue referral to hospital for investigation of iron deficiency
- erroneous assumption that anaemia was due to malabsorption at hospital
- substandard medical care at hospital during medical ward admission
- late diagnosis of colonic cancer resulting in deteriorated patient condition before surgery
- patient's significantly declined functional status at time of surgery
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