Coronial
VIChospital

Finding into death of Thelma Annie Ogilvy

Deceased

Thelma Annie Ogilvy

Demographics

90y, female

Coroner

Coroner Leveasque Peterson

Date of death

2019-11-02

Finding date

2023-05-30

Cause of death

abdominal sepsis complicating perforated diverticular abscess of the sigmoid colon

AI-generated summary

Thelma Annie Ogilvy, a 90-year-old woman from rural Victoria, died from abdominal sepsis complicating a perforated diverticular abscess. She presented with bowel obstruction requiring laparotomy on 21 October 2019, was discharged on 30 October appearing recovered, then re-presented on 31 October with signs of infection. She was transferred to Dandenong Hospital on 1 November but deteriorated rapidly on 2 November, suffering cardiac arrest and death at 5:33pm. The coroner found her medical management by both West Gippsland Healthcare Group and Monash Health was reasonable and appropriate. While delays occurred in securing transfer (28 hours), these did not contribute to her death as she remained clinically stable throughout. The autopsy revealed peritonitis with pus from perforated sigmoid diverticular abscess. The coroner concluded her death was not preventable despite appropriate medical care, noting her significant comorbidities and frailty made recovery less likely following major surgery.

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Specialties

general surgerycolorectal surgeryintensive carecardiologyemergency medicine

Drugs involved

apixaban

Clinical conditions

abdominal sepsisperforated diverticular abscessdiverticulitissmall bowel obstructionNSTEMIatrial flutterperitonitisischemic heart diseasehypertensionpolymyalgia rheumatica

Procedures

laparotomyadhesiolysispharyngeal pouch repair

Contributing factors

  • perforated diverticular abscess
  • post-operative complication following laparotomy
  • NSTEMI sustained on second presentation
  • atrial flutter
  • significant comorbidities and frailty
  • delayed recognition of perforation

Coroner's recommendations

  1. Monash Health review its processes to ensure timely notification of referring hospitals and doctors with regard to patient outcomes
Full text

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