Deceased
Trevor Anthony Peterson
Demographics
57y, male
Coroner
Coroner Simon McGregor
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. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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