Coronial
TASaged care

Coroner's Finding: Ball, Betty Irene

Deceased

Betty Irene Ball

Demographics

67y, female

Date of death

2016-02-02

Finding date

2018-01-29

Cause of death

perforated sigmoid volvulus with peritonitis upon a background of spinocerebellar ataxia

AI-generated summary

Betty Irene Ball, aged 67, died from perforated sigmoid volvulus with peritonitis on 2 February 2016. She had spinocerebellar ataxia and was resident in aged care. She developed constipation from 15 January 2016, but medical review was not sought until 26 January—11 days later. The coroner found this delay regrettable. Dr S. indicated she would expect notification by day 7 and would have escalated to emergency assessment given Mrs Ball's deteriorating condition. While not definitively preventable, earlier medical attention around day 7 may have resulted in earlier hospital presentation and potentially improved survival. The aged care facility's protocols were inadequate; a new system now provides automatic alerts for bowel inactivity, addressing this systemic weakness.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general practiceemergency medicinecolorectal surgeryintensive carepalliative caregeriatric medicine

Error types

delaysystem

Drugs involved

paracetamoltrimethoprimnulaxsennaagarolsodium citrate enemafleet enema

Clinical conditions

spinocerebellar ataxiaconstipationbowel obstructionsigmoid volvulusperitonitisbowel perforationbladder infection

Procedures

colonoscopic depressionopen laparotomybowel resectionstoma formation

Contributing factors

  • delay in seeking medical review for constipation
  • constipation not reported to general practitioner until 11 days after onset
  • inadequate bowel management protocol at aged care facility
  • delay in ambulance attendance (non-urgent classification)
  • pharmacy closure on Australia Day preventing timely delivery of enema prescription
Full text

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