Deceased
Md Fakrul Alam Sozon
Demographics
33y, male
Coroner
Coroner Audrey Jamieson
Date of death
2020-10-10
Finding date
2023-08-14
Cause of death
Haemoperitoneum secondary to lacerated spleen as a result of peritoneal ascitic fluid tap procedure, on a background of liver failure with veno-occlusive liver disease
AI-generated summary
A 33-year-old man with severe alcoholic liver disease (Child-Pugh C) and poor prognosis died from haemoperitoneum following splenic laceration during a diagnostic ascitic tap procedure. Two junior doctors (HMOs/Basic Physician Trainees) performed the procedure unsupervised without formal ultrasound training, mistaking the spleen for ascitic fluid. Critical failures included: absence of senior supervision despite protocol suggesting registrar oversight, lack of formal ultrasound competency training and credentialling, failure to use percussion technique as per protocol, and misinterpretation of ultrasound imaging. While the coroner found no adverse findings against the junior doctors who acted under instruction and appropriately abandoned the procedure when complications arose, significant clinical governance failures were identified. The coroner could not find the death preventable given the patient's terminal prognosis, but emphasised missed opportunities for appropriate care and recommended formal ultrasound training and credentialling systems.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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