Sharon Lee McDonald, a 47-year-old woman with Down syndrome, died from large intestinal infarction secondary to volvulus (twisting of bowel). She was admitted with presumed faecal loading causing bowel obstruction but developed sigmoid volvulus with haemorrhagic infarction. She had known megacolon requiring careful dietary management and regular laxatives. The coroner found no evidence of procedural injury from nasogastric intubation. The death resulted from a vascular catastrophe (complete bowel twist causing tissue death from lack of blood supply) in a patient with complex medical needs. Better recognition of volvulus risk in megacolon patients and potentially earlier imaging or surgical intervention might have prevented this outcome, though the acute nature of volvulus limits preventability.
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Specialties
gastroenterologygeneral medicinegeneral surgery
Error types
diagnostic
Drugs involved
lactulose
Clinical conditions
Down syndromemegacolonvolvulusintestinal infarctionbowel obstructionfaecal loadingarterial septal defectpulmonary hypertensionaspiration pneumonia
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