Deceased
Alan Edward Stewart
Demographics
70y, male
Coroner
Coroner Paul Lawrie
Date of death
2018-08-16
Finding date
2024-08-08
Cause of death
haemoperitoneum, ruptured spleen, colonoscopy
AI-generated summary
Alan Stewart, age 70, died from haemoperitoneum and ruptured spleen approximately 36 hours after an elective colonoscopy at Royal Melbourne Hospital. A splenic injury occurred during the procedure, likely due to mechanical trauma from colonoscope manipulation and pre-existing adhesions between the spleen and mesentery. While splenic injury from colonoscopy is extremely rare and not preventable by standard clinical measures, critical system failures occurred post-discharge: discharge information was inadequate regarding internal bleeding symptoms, and a Nurse-on-Call triage nurse failed to escalate the patient's call to 000 Emergency despite clear signs of shock (breathlessness, dizziness, pallor). Earlier emergency assessment and care may have prevented death through blood transfusion and possible angiographic embolization. Key lessons: improve post-procedure discharge documentation, ensure clear emergency symptom recognition in triage algorithms, and emphasise that any serious symptoms within 48 hours post-procedure warrant emergency evaluation.
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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