Coroner's Finding: Forward, Trudi Maree

Contributing factors

• failure to identify mesenteric ischaemia as differential diagnosis in ED and early assessment
• radiologist's failure to identify occluded superior mesenteric artery on CT scan
• missed diagnosis on initial CT referral form which did not mention SMA occlusion as differential
• non-diagnostic laparoscopy which did not conclusively identify ischaemia
• vascular surgeon's decision to transfer patient to RHH rather than treat at LGH despite proximity and availability
• delay in requesting ambulance transfer (1 hour 43 minutes after transfer accepted)
• delay in dispatching ambulance (1 hour 39 minutes after arrival at LGH)
• delay in commencing surgery at RHH (5 hours after arrival)
• failure of medical staff to escalate overnight despite severe persistent pain and MET call requirement
• Type II diabetes
• obesity
• chronic alcohol dependence
• subsequent thrombosis of SMA identified at post-mortem

Coroner's recommendations

1. Tasmanian Health Service should carry out a review of the circumstances of Mrs Forward's transfer which may identify shortcomings in the patient transport system and facilitate improvements
2. Improve awareness among ED clinicians and surgical registrars of mesenteric ischaemia as a differential diagnosis in acute abdominal pain presentations, particularly in older patients
3. Radiologists should consider mesenteric ischaemia and SMA occlusion in their differential diagnoses when reviewing CT scans for acute abdominal pain, particularly when clinical history indicates risk factors
4. Vascular surgery services should establish protocols to enable urgent treatment of mesenteric ischaemia at regional hospitals when a vascular surgeon is available and the clinical situation is time-critical
5. Review and improve efficiency of inter-hospital transfer processes to minimize delays in transporting patients with time-critical surgical emergencies