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. Report an inaccuracy.
Specialties
Error types
Clinical conditions
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