Coroner's Finding: Summerfeldt; Ian Patrick
Deceased
Ian Patrick Summerfeldt
Demographics
48y, male
Date of death
2014-10-23
Finding date
2017-01-03
Cause of death
sepsis and renal failure due to perforated gastric ulcer
AI-generated summary
A 48-year-old man with hepatitis C and schizo-affective disorder presented to West Coast District Hospital on 20 October 2014 with severe abdominal pain radiating to the right shoulder tip, generalised tenderness, and a pain rating of 8/10. Clinical observations were normal and he self-discharged. He re-presented on 22 October in shock with slurred speech, mottled skin, and pale appearance, found lying outside his home. Despite worsening pain throughout the afternoon, imaging showed only faecal loading and constipation was diagnosed. A ruptured pyloric ulcer causing peritonitis was not recognised until 9pm when he was found on the floor in shock. Transfer to the surgical centre was delayed until 11:40pm. Emergency laparotomy revealed 3 litres of faecal matter in the peritoneal cavity and a 10mm perforation. He died of sepsis and renal failure the following morning. The clinical lesson is that severe abdominal pain with shoulder-tip radiation and peritoneal signs requires urgent surgical consideration and immediate transfer, even with seemingly normal vital signs in younger patients who compensate well.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- failure to recognise peritonitis on initial presentation
- underestimation of severity of illness
- delayed surgical transfer
- patient non-compliance and self-discharge
- inadequate consideration of surgical diagnoses in acute abdominal pain
- emphysema as significant comorbidity
Full text
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