Coroner's Finding: Mrs M
Demographics
female
Date of death
2020-04-17
Finding date
2021-08-13
Cause of death
multi-organ failure
AI-generated summary
Mrs M died from multi-organ failure following recurrent intra-abdominal sepsis and surgical complications after endoscopic duodenal perforation in June 2019. During resection of a duodenal adenoma, perforation occurred requiring emergency laparotomy. The surgeon was unable to completely close the perforation. The coroner found that post-perforation management was of appropriate standard, but questioned whether a Whipple procedure should have been performed initially rather than simple resection. Had a Whipple been performed, duodenal perforation would likely have been avoided. However, the decision between approaches was acknowledged as clinically complex, with resection being reasonable given the adenoma's malignant potential and no detected malignancy on biopsy. The clinical lesson emphasizes careful risk-benefit analysis when planning duodenal adenoma resection.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- endoscopic duodenal perforation during adenoma resection
- incomplete closure of duodenal perforation at initial emergency surgery
- recurrent intra-abdominal sepsis
- acute pancreatitis
- patient delay in seeking medical intervention in April 2020 due to prior adverse experience
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