Finding into death of Alan Edward Stewart
Deceased
Alan Edward Stewart
Demographics
70y, male
Date of death
2018-08-17
Finding date
2024-08-08
Cause of death
haemoperitoneum and ruptured spleen following colonoscopy
AI-generated summary
Alan Stewart, aged 70, died from a ruptured spleen about 24 hours after an elective colonoscopy at Royal Melbourne Hospital. The splenic injury resulted from mechanical trauma during the procedure—an extremely rare complication that can occur despite proper technique. The critical failures were in post-procedure management. The discharge information was vague about internal bleeding symptoms and failed to clearly distinguish when to call emergency services versus a GP. When Mr Stewart's wife called Nurse-on-Call that evening reporting breathlessness and dizziness, the triage nurse failed to recognize this as an emergency requiring 000 transfer, instead advising to see a doctor within 12 hours. Expert evidence suggested timely emergency assessment and care might have prevented death. Key recommendations included improving discharge information to clearly list internal bleeding symptoms and emergency action triggers, and recording discharge information provided to patients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- splenic injury from mechanical trauma during colonoscopy procedure
- inadequate post-discharge information about internal bleeding symptoms
- failure of Nurse-on-Call triage nurse to recognize breathlessness as an emergency requiring transfer to 000
- delay in accessing emergency medical care
Coroner's recommendations
- Melbourne Health review written patient discharge information to: remove ambiguity concerning appropriate emergency action for serious symptoms such as breathing difficulties; include complete symptoms of significant internal haemorrhage; emphasise significance of post-operative period
- Melbourne Health review patient discharge procedures to ensure a record is kept of discharge information provided to the patient
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