Deceased
Christine Ann Stephen
Demographics
67y, female
Coroner
Coroner Audrey Jamieson
Date of death
2017-11-08
Finding date
2023-02-22
Cause of death
Intra-abdominal sepsis complicating an anastomotic leak following elective surgery to repair a vesico-colic fistula
AI-generated summary
A 67-year-old woman died from intra-abdominal sepsis following an anastomotic leak from elective colorectal surgery to repair a vesico-colic fistula. The initial surgery on 1 November 2017 was appropriately performed, and the anastomotic leak was detected and managed surgically on 6 November with transfer to ICU. Critical opportunities were missed in the post-ICU care: nursing staff failed to escalate deteriorating signs (increasing lactate and vasopressor requirements) to consultant intensivists on multiple occasions; consultant surgeon and intensivist did not attend the patient in person despite concerning clinical trajectory; and early diagnosis of sepsis was not made. While experts disagreed on whether earlier interventions would have changed outcome, the coroner identified substantial opportunities missed in optimising post-operative care. The case highlights failures in escalation protocols, documentation of clinical discussions, and the importance of consultant-level assessment in severe sepsis.
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
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…
75y · Male·Multiorgan dysfunction syndrome complicating anastomotic leak following hemicole…
A 75-year-old man died from multiorgan dysfunction following an anastomotic leak after hemicolectomy for caecal adenocarcinoma. Initial post-operative recovery appeared normal, but he deteriorated from day 3 onwards. The…
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