Coroner's Finding: Fenton, Timothy John
Deceased
Timothy John Fenton
Demographics
57y, male
Date of death
2017-10-01
Finding date
2018-11-08
Cause of death
sepsis and multiple organ failure secondary to aspiration pneumonia
AI-generated summary
Timothy Fenton, a 57-year-old intellectually disabled man on antiepileptic medications, developed a small bowel ileus after presenting with vomiting and diarrhoea. Following emergency laparotomy, his nasogastric tube was dislodged on 29 August and not reinserted during the morning ward round despite clinical stability. Later that day, when the tube was reinserted and a chest x-ray confirmed correct gastric placement showing gaseous distension, the tube was not aspirated to decompress the stomach. Within one hour, Mr Fenton aspirated gastric contents, developing aspiration pneumonia, acute respiratory distress syndrome, and ultimately sepsis with multiple organ failure leading to death on 1 October 2017. The coroner found the failure to aspirate the nasogastric tube after confirming correct placement was a departure from reasonable medical care that directly contributed to death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- ileus
- failure to aspirate nasogastric tube despite confirmed gastric placement
- nasogastric tube dislodgement not reinserted
- aspiration of gastric contents
- antiepileptic medication potentially contributing to ileus development
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