Coroner's Finding: LA
Demographics
67y, male
Date of death
2019-08-27
Finding date
2021-08-20
Cause of death
acute gastrointestinal haemorrhage complicating peptic ulcer of the duodenum with erosion into gastro-duodenal artery
AI-generated summary
A 67-year-old man died from acute gastrointestinal haemorrhage from a duodenal ulcer following complex post-operative complications from laparoscopic Hartmann's procedure for diverticulitis. Key clinical lessons: (1) Early persistent elevation of C-reactive protein post-colorectal surgery is a recognized marker of anastomotic leak—a 5-day diagnostic delay occurred despite these indicators; (2) Proton pump inhibitor (Esomeprazole) charting failed from 6 August onwards despite the patient's known reflux oesophagitis and pre-admission use of Rabeprazole; multiple practitioners failed to recognize this omission; (3) Post-9 August treatment was appropriate, but earlier sepsis recognition and continued acid suppression might have prevented the final catastrophic bleed. Clinicians should maintain vigilance for anastomotic complications using biomarkers and ensure medication reconciliation during transitions of care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- delay in diagnosis of anastomotic leak (5 days post-surgery)
- failure to recognize early and persistent elevated C-reactive protein as marker of anastomotic leakage
- inaccuracy in drug chart transcription of Esomeprazole
- failure of multiple medical practitioners to recognize cessation of proton pump inhibitor from 6 August 2019
- post-surgical complications including faecal peritonitis and sepsis
- acute kidney failure requiring dialysis
- atherosclerotic coronary vascular disease
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —