Coroner's Finding: Kenney, Margaret Patricia
Deceased
Margaret Patricia Kenney
Demographics
83y, female
Date of death
2017-11-13
Finding date
2019-04-18
Cause of death
upper gastrointestinal bleed with haemodynamic compromise following anticoagulation for atrial fibrillation
AI-generated summary
Margaret Patricia Kenney, 83, died from upper gastrointestinal bleeding complicated by cardiac arrest while anticoagulated for atrial fibrillation. She had been diagnosed with gastro-oesophageal reflux disease (GORD) in 2015 and prescribed pantoprazole 40mg daily. During her final hospital admission (29 October to 13 November 2017), pantoprazole was not administered or documented as withheld, despite no clear clinical rationale. The coroner accepted expert opinion that a gastric or duodenal ulcer causing the fatal haemorrhage would likely have been prevented had PPI therapy continued, particularly in a patient receiving anticoagulation. Additional failures included lack of surgical review for undifferentiated abdominal pain, inadequate symptom investigation, and poor medication documentation. The coroner found the death was likely preventable.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- discontinuation of proton pump inhibitor (pantoprazole) without documented rationale
- lack of surgical review for undifferentiated abdominal pain
- thyrotoxicosis
- congestive cardiac failure
- atrial fibrillation requiring anticoagulation
- hypertension
- diabetes mellitus type II
- treatment of symptoms without investigation of underlying cause
- inadequate medication documentation
Coroner's recommendations
- All cases involving undifferentiated abdominal pain should be reviewed by the surgical team in the first instance regardless of abdominal imaging results
- Clear and unambiguous documentation must be maintained concerning any medications being withheld, including the rationale for withholding
- When medications must be withheld, alternative agents should be sought to continue treating pre-existing chronic diseases
- For patients on proton pump inhibitors, there should be clear assessment of ongoing need for the drug, with alternative PPI agents prescribed if indicated, particularly for patients receiving anticoagulation
- Symptoms such as nausea and vomiting should prompt investigation of underlying cause rather than symptomatic treatment alone
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