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. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
74y · Male·small intestinal ischaemia caused by aortic atherosclerosis
A 74-year-old man presented to hospital with abdominal pain following a fall. He developed hypotension, fever, tachycardia, and elevated inflammatory markers consistent with sepsis within hours of admission. Despite clea…
73y · Male·sepsis due to ischemic gut due to occlusion of the superior mesenteric artery
A 73-year-old man presented with acute severe abdominal pain caused by superior mesenteric artery (SMA) occlusion. Initial CT angiogram at 12:30am was reported as normal; the SMA occlusion was not identified until 4:45am…
73y · Female·sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopi…
A 73-year-old woman died from sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopic revision of gastric bypass surgery. She had complex medical history with multiple post-operative complicatio…
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. Some material may have been redacted or restricted by court order or privacy requirements. 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 — report an inaccuracy here.