Finding into death of Paul Desmond Smith
Deceased
Paul Desmond Smith
Demographics
58y, male
Date of death
2018-11-23
Finding date
2022-11-29
Cause of death
complications of large bowel pseudo-obstruction
AI-generated summary
Paul Desmond Smith, aged 58, died from complications of large bowel pseudo-obstruction following discharge from hospital after inadequate assessment. He had presented to the ED with lower abdominal pain and severe faecal loading (bowel dilation 19cm). Despite a critical admission one year prior requiring ICU and manual disimpaction, and clear risk factors for recurrent obstruction, he was discharged after only symptomatic treatment with laxatives and enema. The morning ward round assessment was cursory, with minimal documentation and no appreciation of his high-risk status. No consideration was given to urinary retention (present on imaging), repeat imaging to confirm improvement, or operative intervention. Key clinical lessons: high-risk patients with recurrent pseudo-obstruction require prolonged inpatient management, not symptom-triggered discharge; previous critical illness should guide conservative decision-making; and comprehensive documentation of clinical reasoning is essential for continuity of safe care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- inadequate assessment during morning ward round
- failure to appreciate high-risk status based on previous critical admission
- premature discharge without objective confirmation of improvement
- minimal documentation of management plan and discharge decision
- lack of appreciation of urinary retention and other complications
- failure to arrange surgical follow-up or colorectal referral after November 2017 admission
- non-compliance with appointments and colonoscopy
- limited health literacy
- chronic untreated bowel motility impairment
Coroner's recommendations
- Western Health should improve the quality of documentation of assessments, clinical findings, and discharge plans
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