Finding into death of Susan Bourke
Deceased
Susan Bourke
Demographics
49y, female
Date of death
2009-09-01
Finding date
2016-08-18
Cause of death
Widespread small and large bowel, splenic and hepatic infarction secondary to severe aortic atherosclerosis
AI-generated summary
Susan Bourke, a 49-year-old woman, died from widespread small and large bowel infarction secondary to severe aortic atherosclerosis causing critical stenosis of the superior mesenteric and coeliac arteries. She presented to the ED with months of abdominal pain, weight loss and diarrhoea, initially suspected to be ulcerative colitis. A CT scan on 26 August identified splenic infarcts but failed to recognize the critical arterial stenosis. Subsequent clinical deterioration led to emergency laparotomy 5 days later, revealing bowel infarction incompatible with life. While the CT scan findings were difficult to diagnose prospectively even for consultant radiologists, critical documentation gaps prevented clear understanding of whether mesenteric ischaemia was adequately considered during initial assessment. Clinicians should maintain complete clinical records of verbal discussions with radiologists and remain alert to mesenteric ischaemia in patients with unexplained abdominal pain, weight loss, and elevated lactate.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Failure to identify critical arterial stenosis on CT imaging
- Inadequate documentation of discussions between clinicians and radiologist regarding CT request
- Ulcerative colitis presumptively treated, delaying consideration of mesenteric ischaemia
- Non-specific CT imaging protocol not optimized for mesenteric vessel assessment
- Delay in diagnostic imaging and clinical intervention
- Unknown entity providing verbal CT report with unclear communication of findings
Coroner's recommendations
- Health care providers must maintain complete and accurate clinical records documenting discussions between treating staff and radiologists regarding imaging requests
- Documentation must clearly identify who provided and received verbal reports of imaging findings
- Clinical notes must record the identities of radiologists who reviewed imaging studies and the substance of their findings
- Clinicians should maintain awareness of mesenteric ischaemia as a differential diagnosis in patients presenting with abdominal pain, weight loss, and elevated lactate, particularly when findings are inconsistent with presumptive diagnoses such as inflammatory bowel disease
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