Deceased
Agostino Cutugno
Demographics
57y, male
Coroner
Coroner Simon McGregor
Date of death
2017-08-23
Finding date
2019-08-30
Cause of death
Small bowel perforation complicating small bowel obstruction arising from intra-abdominal adhesions
AI-generated summary
Agostino Cutugno, a 57-year-old prisoner with intellectual disability (IQ 55) and history of self-inflicted abdominal stab wounds, died from small bowel perforation complicating obstruction due to intra-abdominal adhesions. Care was fragmented across five locations over 19 days with multiple teams managing his condition. Key clinical lesson: prisoners with cognitive disabilities require early family involvement to provide medical history context and support decision-making. The coroner found medical teams provided reasonable care despite communication challenges, but highlighted systemic gaps in ensuring family access during emergencies. Medical management of the obstruction, bleeding, and surgical interventions were appropriate, but family visiting restrictions in ICU initially prevented access when family input was clinically valuable.
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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58y · Male·complications of large bowel pseudo-obstruction
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