Deceased
Neita Jean Little
Demographics
79y, female
Date of death
2014-06-28
Finding date
2014-03-14
Cause of death
aspiration pneumonia caused by aspiration of emesis secondary to small bowel obstruction, which resulted from longstanding peritoneal adhesions and a post-operative haematoma at the surgical site
AI-generated summary
Mrs Little, 79, died from aspiration pneumonia caused by small bowel obstruction post-hysterectomy surgery. The obstruction resulted from both pre-existing adhesions and a post-operative haematoma at the surgical site. Critical clinical lessons: (1) repeated vomiting unresponsive to anti-emetics warrants urgent investigation; (2) oxygen desaturation (3am) was a red flag requiring medical review and imaging which was not obtained; (3) Dr J.'s assessment at 9.45am, concluding discharge fitness despite seven vomiting episodes in 15 hours and low oxygen saturation, was inappropriate. The 3am desaturation should have prompted urgent imaging that might have identified the evolving obstruction before aspiration occurred. Nursing staff appropriately escalated concerns but medical response was inadequate.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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