Coronial
TAShospital

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 Bell 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. Report an inaccuracy.

Specialties

general practicegeneral surgeryhaematologygastroenterologyemergency medicine

Error types

diagnosticcommunicationdelay

Clinical conditions

iron deficiency anaemiacolonic adenocarcinomamalabsorptionshort bowel syndromeretroperitoneal fibrosis

Procedures

right hemicolectomycolonoscopygastroscopy

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
Full text

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.