Coroner's Finding: Kenney, Margaret Patricia

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

1. All cases involving undifferentiated abdominal pain should be reviewed by the surgical team in the first instance regardless of abdominal imaging results
2. Clear and unambiguous documentation must be maintained concerning any medications being withheld, including the rationale for withholding
3. When medications must be withheld, alternative agents should be sought to continue treating pre-existing chronic diseases
4. 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
5. Symptoms such as nausea and vomiting should prompt investigation of underlying cause rather than symptomatic treatment alone