Finding into death of Ms T
Deceased
Ms T
Demographics
48y, female
Date of death
2023-02-21
Finding date
2024-06-27
Cause of death
Pneumonia on a background of subacute bowel obstruction secondary to metastatic sigmoid colorectal cancer
AI-generated summary
Ms T, a 48-year-old woman with cerebral palsy and intellectual disability living in specialist disability accommodation, died from pneumonia with subacute bowel obstruction secondary to metastatic sigmoid colorectal cancer. She presented with non-specific symptoms (lethargy, increased bowel movements) in December 2022, was investigated for UTI and infection, and discharged. Her family raised concerns about delayed cancer diagnosis and requested additional investigations during her November 2022 presentation. The Coroners Prevention Unit reviewed care and found no missed diagnostic opportunities—the borderline anaemia and mild iron deficiency were not typical for iron deficiency anaemia at the time, and her clinical improvement post-treatment made further investigation at discharge reasonable. The significant haemoglobin drop post-discharge prompted CT imaging on re-presentation in January 2023, which identified the inoperable malignancy. No preventable failures in care were identified.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- metastatic sigmoid colorectal cancer
- subacute bowel obstruction
- bronchopneumonia
- reduced oral intake post-discharge
- difficulty with symptom management in community setting
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