Coronial
VIChospital

Finding into death of John Edward Hadland (Millar)

Deceased

John Edward Hadland (Millar)

Demographics

38y, male

Coroner

Coroner Paul Lawrie

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. Report an inaccuracy.

Specialties

surgeryintensive careemergency medicineanaesthesiagastroenterology

Error types

proceduralsystem

Drugs involved

macrogollactuloseantibioticsiv fluidsanalgesiainotropessedation

Clinical conditions

sepsisaspiration pneumoniasmall bowel obstructionfaecal loadingproctitispneumothoraxseptic shockchromosome 1 short arm deletion syndromeintellectual disabilityscoliosis

Procedures

laparotomyadhesion divisiongastronomy tube insertionintubationcentral line insertion (subclavian)extubation

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
Full text

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