Deceased
RDZ
Demographics
11y, male
Coroner
Coroner Dimitra Dubrow
Date of death
2022-03-24
Finding date
2024-11-22
Cause of death
complications of bowel obstruction in the setting of chronic constipation
AI-generated summary
RDZ was an 11-year-old Aboriginal boy who died from complications of bowel obstruction secondary to chronic constipation with a fecalith. He had been under paediatric care for years with multiple admissions for bowel washouts. Despite referral to RCH paediatric surgery in 2021, his examination under anaesthesia was delayed until after the surgeon's leave, scheduled for February 2022. On 23 March 2022, the family ran out of Parachoc (liquid paraffin) due to financial constraints, leading to rapid deterioration. He presented to Bairnsdale ED on 24 March with severe abdominal distension, lactic acidosis, and signs of shock. Critical gaps in emergency care included incomplete triage assessment, absent blood pressure recordings throughout ED stay, and placement in an unmonitored room. He was transferred to RCH where emergency surgery revealed massive fecal impaction, megacolon, and hypoganglionosis. Despite surgery and intensive care, he died from multi-organ failure and uncontrollable bleeding. Key preventable factors included: failure to refer to Wadja Aboriginal support services, inadequate coordination between rural and tertiary services, financial barriers to medications, and systemic ED assessment failures.
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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BCT was a 2-year-old Aboriginal child with complex needs from a genetic disorder (CAMTA1 mutation) who died from hypoxic-ischaemic encephalopathy following sepsis related to bowel perforation after a percutaneous endosco…
33y · Male·Haemoperitoneum secondary to lacerated spleen as a result of peritoneal ascitic …
A 33-year-old man with severe alcoholic liver disease (Child-Pugh C) and poor prognosis died from haemoperitoneum following splenic laceration during a diagnostic ascitic tap procedure. Two junior doctors (HMOs/Basic Phy…
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