Coroner's Finding: Whitney, David Ian
Deceased
David Ian Whitney
Demographics
73y, male
Date of death
2022-03-12
Finding date
2024-08-05
Cause of death
sepsis due to ischemic gut due to occlusion of the superior mesenteric artery
AI-generated summary
A 73-year-old man presented with acute severe abdominal pain caused by superior mesenteric artery (SMA) occlusion. Initial CT angiogram at 12:30am was reported as normal; the SMA occlusion was not identified until 4:45am—over 4 hours later—when surgical staff reviewed the scan. This delay meant the patient underwent exploratory laparotomy at Launceston General Hospital (LGH) rather than proceeding directly to Royal Hobart Hospital (RHH) for vascular intervention. By the time revascularisation was attempted at RHH, extensive bowel ischemia had developed, ultimately proving non-viable. The coroner found that requesting the radiologist specifically to evaluate for mesenteric ischemia before the initial CT scan might have enabled earlier diagnosis and treatment at a specialist centre, potentially improving outcome. However, given the difficulty of diagnosing acute mesenteric ischaemia and the clinical uncertainty regarding whether earlier intervention would have altered the ultimate fatal outcome, the coroner did not criticise the LGH clinicians' management.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- delayed identification of SMA occlusion on initial CT scan
- failure to communicate mesenteric ischemia as differential diagnosis to radiologist prior to scan
- extended time interval (4+ hours) between initial CT and diagnosis
- extensive bowel ischemia by time of revascularisation attempt
- coagulopathy and sepsis
Coroner's recommendations
- Hospital clinicians requesting radiological investigations should, whenever possible, bring to the attention of the radiologist all relevant differential diagnoses for investigation and reporting
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