Finding into death of Alan Edward Stewart
Deceased
Alan Edward Stewart
Demographics
70y, male
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.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- mechanical trauma to spleen during colonoscopy procedure
- adhesions between spleen and mesentery/splenocolic ligament
- tension transmitted via splenocolic ligament from colonoscope manipulation
- inadequate post-discharge complications information
- failure of Nurse-on-Call triage nurse to recognise airway-breathing-circulation compromise
- incorrect assessment of ABC compromise evaluation question
- failure to transfer call to emergency services despite breathlessness and signs of shock
Coroner's recommendations
- Melbourne Health to review written patient discharge information to: (a) remove ambiguity concerning appropriate emergency action for serious symptoms such as breathing difficulties; (b) include complete symptoms of significant internal haemorrhage among serious symptoms requiring emergency action; (c) emphasise significance of post-operative period when considering symptoms
- Melbourne Health to review patient discharge procedures to ensure record is kept of discharge information provided to patient
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