Deceased
Wendy Crosswell
Demographics
69y, female
Date of death
2015-12-12
Finding date
2017-06-20
Cause of death
peritonitis due to dislodged percutaneous endoscopic gastrostomy (PEG) tube
AI-generated summary
A 69-year-old woman with pyelonephritis developed peritonitis and died after a percutaneous endoscopic gastrostomy (PEG) tube became dislodged. The tube dislodgement was suspected on 11 December 2015 when the patient was observed agitated and scratching at her skin. However, the subsequent fluoroscopic examination was incorrectly interpreted as showing the tube in correct position. No antibiotics were given and investigation was not expeditious. The coroner found the care substandard, particularly regarding radiological reporting and failure to act on suspicion of tube displacement. Despite this, the coroner noted the patient was gravely ill with little realistic chance of functional recovery from her underlying pyelonephritis, and therefore concluded the substandard care did not change her probable outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
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