Coroner's Finding: FL de-identified
Deceased
FL
Demographics
17y, unknown
Date of death
2020-07-13
Finding date
2022-02-18
Cause of death
hypoxic brain damage from out of hospital cardiac arrest
AI-generated summary
FL was a 17-year-old with complex medical needs including short bowel syndrome and dependence on total parenteral nutrition (TPN) via central vascular access device. In June 2020, he became severely unwell with deteriorating function, bedsores, and immobility, but was not taken for medical evaluation despite obvious grave illness observed by school staff and social worker. On 2 July 2020, he aspirated while drinking water, suffered out-of-hospital cardiac arrest, and died from hypoxic brain damage. Contributing factors included his underlying short bowel syndrome, liver/pancreatic/splenic dysfunction from long-term TPN, and possible aspiration or sepsis. Key clinical lessons: early recognition of deterioration in medically complex adolescents is critical; concerning observations by school/social staff should trigger mandatory safeguarding responses; and barriers to medical care (patient reluctance, parental hesitancy) must be overcome when serious illness is evident.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- short bowel syndrome secondary to gastroschisis
- liver dysfunction from long-term total parenteral nutrition
- pancreatic dysfunction from long-term total parenteral nutrition
- splenic dysfunction from long-term total parenteral nutrition
- possible aspiration of gastric contents
- possible sepsis from central vascular access device
- prolonged immobility and bedsores
- inadequate medical evaluation during period of deterioration
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