Deceased
Robert Charles Avery
Demographics
86y, male
Coroner
Deputy State Coroner Iain West
Date of death
2010-07-20
Finding date
2015-07-01
Cause of death
Septic shock secondary to urosepsis
AI-generated summary
Robert Avery, 86, was admitted to Valley Private Hospital for colonoscopy to investigate constipation. After the procedure was cancelled due to respiratory concerns, he was managed with fluid restriction, bowel preparation, and insulin adjustment. Despite overnight clinical deterioration (low blood pressure, rectal bleeding, poor oral intake), he was discharged on day 2. An emergency physician reviewed him post-midnight, ordered blood tests for morning, but did not directly communicate findings to the treating surgeon. The surgeon did not review the physician's notes or the ordered blood tests before discharge. Avery was readmitted next day with sepsis from a resistant urinary tract infection and died of septic shock. Key failures included: failure to review progress notes and blood test results before discharge, inadequate fluid balance documentation, poor communication between physicians, and failure to alert the treating doctor to abnormal pathology results. Early recognition of sepsis and appropriate fluid management might have altered the outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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70y · Male·haemoperitoneum, ruptured spleen, colonoscopy
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