Coroner's Finding: de-identified RS
Demographics
68y, male
Date of death
2023-09-16
Finding date
2025-06-17
Cause of death
Exsanguination due to peptic ulcer of the duodenum with erosion into the gastroduodenal artery
AI-generated summary
A 68-year-old man presented to the emergency department with two episodes of fresh rectal bleeding and elevated blood urea. Despite stable vital signs, he was discharged after two hours with haemorrhoid suppositories and an outpatient appointment, without formal diagnosis or investigation. The coroner found that clinicians should have considered upper gastrointestinal bleeding as a differential diagnosis, particularly given the elevated urea and characteristic pattern of bleeding that stops then recurs. They should have assessed for haemodynamic instability and undertaken further investigations before discharge. The patient died that afternoon from exsanguination due to a bleeding duodenal ulcer eroding into the gastroduodenal artery. The coroner concluded that if the patient had remained in hospital for investigation, the bleeding source would have been identified, allowing life-saving treatment. Key lessons include maintaining diagnostic rigour, considering differential diagnoses systematically, and not discharging patients without established diagnoses.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Failure to establish a diagnosis before discharge
- Failure to consider upper gastrointestinal bleeding as a differential diagnosis
- Failure to assess for haemodynamic instability despite elevated blood urea
- Failure to perform haemodynamic assessment including orthostatic hypotension testing
- Inadequate investigation of recurrent bleeding episodes
- Discharge without diagnostic investigation
- Misattribution of bleeding to haemorrhoids without excluding other sources
Coroner's recommendations
- Development of guidelines for the management of suspected gastrointestinal haemorrhage
- Review of emergency department criteria and practice around undertaking vital signs of patients
- Implementation of these recommendations by the hospital and other Tasmanian Health Service emergency departments
Full text
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