Finding into death of John Edward Hadland (Millar)
Deceased
John Edward Hadland (Millar)
Demographics
38y, male
Date of death
2021-09-02
Finding date
2023-04-14
Cause of death
abdominal and chest sepsis complicating iatrogenic left pneumothorax and laparotomy for small bowel obstruction in a man with chromosome 1 short arm deletion syndrome and scoliosis
AI-generated summary
A 38-year-old man with chromosome 1 short arm deletion syndrome, intellectual disability, and scoliosis died from sepsis following iatrogenic pneumothorax and emergency laparotomy for small bowel obstruction. He was admitted with faecal loading and proctitis, deteriorated with small bowel obstruction requiring emergency surgery. Post-operatively he aspirated, developed aspiration pneumonia and septic shock. During central line insertion for inotrope support, an iatrogenic left pneumotharax occurred. The coroner found the care provided by both community support services and the hospital appropriate. The case highlights challenges in managing complex patients with intellectual disability and limited decision-making capacity in acute emergencies, and the importance of early clarification of medical treatment decision-maker status.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- iatrogenic left pneumothorax from central line insertion
- aspiration pneumonia following extubation
- septic shock
- small bowel obstruction
- faecal loading and rectal inflammation
- chromosome 1 short arm deletion syndrome with intellectual disability
- scoliosis complicating management
- difficulty in obtaining/clarifying medical treatment decision-maker status
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