Finding into death of Trevor Anthony Peterson
Deceased
Trevor Anthony Peterson
Demographics
57y, male
Date of death
2020-03-17
Finding date
2022-05-06
Cause of death
Sepsis from ischemic bowel due to superior mesenteric artery thrombus
AI-generated summary
Trevor Peterson, a 57-year-old with chronic gut ischemia, underwent mesenteric artery stenting in February 2020. Discharge instructions emphasising dual antiplatelet therapy (DAPT) were not clearly communicated to the vascular team. He self-ceased aspirin before readmission with stent thrombosis in March 2020. Despite initial improvement on heparin, he deteriorated and required emergency surgery with extensive bowel resection. Multiple laparotomies followed with progressive ischemia. He died of sepsis from ischemic bowel. Key learning: ensure explicit communication of critical post-procedural medications between interventional radiologists and treating teams; improve patient education about medication adherence; and consider earlier escalation when pain persists despite apparent clinical improvement. Communication failures between departments and inadequate handover of discharge instructions were contributing factors.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Superior mesenteric artery stent thrombosis
- Discontinuation of aspirin and statin medications post-procedure
- Inadequate communication of discharge instructions from interventional radiology to vascular surgery team regarding requirement for dual antiplatelet therapy
- Delayed escalation of care despite ongoing abdominal pain
- Incomplete handover of critical post-procedural medication requirements to primary care
- Significant smoking history contributing to underlying vascular disease
Coroner's recommendations
- Western Health should identify and implement actions to improve communication with patients, their families, and their General Practitioners to ensure that preventative measures, particularly as part of post-procedure treatment, are understood and preventative options are maximised.
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