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 secondary to ruptured spleen following colonoscopy
AI-generated summary
Alan Edward Stewart, aged 70, died from haemoperitoneum due to splenic rupture following routine colonoscopy at Royal Melbourne Hospital on 15 August 2018. The splenic injury was caused by mechanical trauma from the colonoscope, an extremely rare complication occurring despite appropriate technique. Critical clinical lessons: (1) Post-discharge advice was inadequate, failing to list symptoms of internal haemorrhage; (2) Nurse-on-Call triage nurse failed to correctly assess airway-breathing-circulation compromise when Mr Stewart presented with breathlessness, dizziness and pallor, resulting in inappropriate advice to see a doctor within 12 hours rather than calling emergency services; (3) Had emergency care been accessed promptly, there was potential for life-saving intervention including transfusion and splenic artery embolization. The coroner found the Nurse-on-Call error resulted in a lost opportunity for timely emergency assessment and care that may have prevented death. Recommendations focused on improving discharge information clarity and documentation procedures.
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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