Coroner's Finding: Revell, Dianne Judith
Deceased
Dianne Judith Revell
Demographics
65y, female
Date of death
2022-08-13
Finding date
2022-11-11
Cause of death
decompensated liver failure
AI-generated summary
Ms Revell, a 65-year-old with Child Pugh Class C cirrhosis secondary to 20 years of heavy alcohol use and hepatitis C, was admitted following an intoxicated fall causing an olecranon fracture. Post-operatively, she developed a small bowel obstruction and rapidly decompensated. Clinical lessons include: recognising that cirrhotic patients metabolise anaesthetics poorly (delayed awakening was a warning sign); early identification of post-operative complications; and proactive family communication regarding serious diagnoses. The coroner found no systemic failures, though the family questioned delayed disclosure of liver disease severity. Her death from decompensated liver failure was ultimately related to end-stage cirrhosis and the physiological stress of trauma and surgery in a severely compromised patient.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- hepatic cirrhosis Child Pugh Class C
- alcoholic liver disease
- hepatitis C infection
- accidental fall while intoxicated
- olecranon fracture requiring surgery
- post-operative small bowel obstruction
- impaired anaesthetic metabolism due to liver disease
- severe malnutrition and poor functional status
- osteoporosis
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