Coroner's Finding: Patterson, Alexander Frank
Deceased
Alexander Frank Patterson
Demographics
65y, male
Date of death
2023-05-22
Finding date
2024-06-27
Cause of death
Bleeding duodenal ulcer
AI-generated summary
A 65-year-old man with type 2 diabetes presented to hospital with haematemesis, hypoglycaemia, and postural hypotension caused by a bleeding duodenal ulcer. He was misdiagnosed with atypical pneumonia causing confusion. Critical diagnostic signs were missed: isolated elevated urea in the context of postural hypotension is characteristic of gastrointestinal bleeding, not infection. Haematemesis and black stool on rectal examination further supported this diagnosis. Poor communication between clinicians meant the elevated urea was not effectively conveyed to the treating team. This diagnostic failure resulted in failure to escalate for urgent endoscopy or surgical intervention, making the death preventable. The coroner identified premature diagnostic closure and communication breakdown as root causes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Failure to diagnose gastrointestinal bleeding at hospital presentation
- Premature diagnostic closure
- Incorrect diagnosis of pneumonia
- Ineffective communication of elevated urea between clinicians
- Failure to recognise haematemesis and black stool as key diagnostic signs
- Failure to escalate care appropriately
Coroner's recommendations
- The Emergency Department at the Mersey Community Hospital consider the introduction of a validated scoring scale and flowchart/pathway for the management of a suspected upper gastrointestinal haemorrhage
- The Tasmanian Health Service conduct audits of medical documentation to ensure it meets the requirements of the relevant NSQHS standard
- The Tasmanian Health Service take timely steps to implement the recommendations specified in the RCA report
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