Deceased
Gerard Alexander Tibballs
Demographics
66y, male
Date of death
2010-06-25
Finding date
2014-12-08
Cause of death
Peritonitis secondary to bowel perforation from small bowel obstruction caused by intra-abdominal adhesions
AI-generated summary
A 66-year-old man with a history of appendectomy presented with vomiting and diarrhoea. His GP, Dr D., ordered an abdominal X-ray on 23 June 2010, suspecting bowel obstruction but did not mark it urgent. The radiologist, Dr T., identified a small bowel obstruction and attempted contact via voicemail. Dr D. assumed the patient would either go to hospital or follow up appropriately but failed to directly contact the patient himself to confirm awareness of the serious diagnosis. The patient remained at home, deteriorated over the following days, and collapsed on 25 June with peritonitis from bowel perforation secondary to adhesions. The coroner found Dr D.'s failure to ensure direct communication with his patient about a known life-threatening condition departed from standard practice. Earlier hospitalisation could have prevented death. Key lessons: ensure patient contact details are recorded; when a serious diagnosis is suspected or confirmed, directly contact the patient to ensure they understand the urgency; do not assume responsibility has been transferred without confirmation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
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