Deceased
Rodney James Hanslow
Demographics
86y, male
Date of death
2021-08-08
Finding date
2023-02-17
Cause of death
progressive cognitive decline/decompensation and gastrointestinal haemorrhage
AI-generated summary
An 86-year-old man with Parkinson's disease and long-standing gastro-oesophageal reflux disease (GORD) sustained a traumatic brain injury from a fall at home on 3 July 2021. He was admitted to hospital on 6 July 2021 with subdural and subarachnoid haemorrhage. While hospitalised, nursing staff documented multiple episodes of melaena (black tarry stools) from 21 July onwards, indicating gastrointestinal bleeding. Critical errors occurred: (1) his proton pump inhibitor (PPI), which he had taken for 14 years to prevent GI ulceration, was discontinued on admission and only given once on 22 July; (2) nursing staff failed to adequately communicate the significant melaena to medical staff; (3) medical staff did not read nursing notes documenting the bleeding. A duodenal ulcer developed and caused fatal gastrointestinal haemorrhage. The coroner found the care was below acceptable standard. Had his PPI been continued and the bleeding promptly recognised and treated, the fatal outcome could have been prevented.
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
82y · Female·traumatic closed head injury (subdural haematoma) resulting from a fall from sta…
Mrs Emily Jones, 82, died from subdural haematoma following an unwitnessed fall at Royal Hobart Hospital on 15 November 2021. She was admitted five days after discharge from Hobart Private Hospital where she was treated …
83y · Female·upper gastrointestinal bleed with haemodynamic compromise following anticoagulat…
Margaret Patricia Kenney, 83, died from upper gastrointestinal bleeding complicated by cardiac arrest while anticoagulated for atrial fibrillation. She had been diagnosed with gastro-oesophageal reflux disease (GORD) in …
80y · Female·subdural haematoma due to closed head injury sustained in a fall from bed in hos…
An 80-year-old woman with chronic heart failure admitted to hospital fell from bed and hit her head. Although nursing staff were concerned about a possible head injury, the House Medical Officer incorrectly concluded no …
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