Finding into death of Peter Ronald Dunmore
Deceased
Peter Ronald Dunmore
Demographics
64y, male
Date of death
2024-06-19
Finding date
2026-09-24
Cause of death
Peritonitis and ischaemic small bowel, with contributing factors of hypertensive and ischaemic heart disease
AI-generated summary
A 64-year-old male with hypertension and smoking history presented to hospital with several weeks of abdominal pain, diarrhoea, and weight loss. Imaging revealed a superior mesenteric artery (SMA) occlusion deemed chronic with adequate collateral blood supply, but blood tests showed markedly elevated inflammatory markers (CRP 237 mg/L). He was discharged without the recommended antiplatelet and lipid-lowering medications, with inadequate documentation provided to his general practitioner regarding the new diagnosis or treatment plan. Subsequent investigations including endoscopy and CT chest occurred, but escalation to hospital was not pursued despite reports of being 'very unwell'. He died at home from peritonitis and ischaemic small bowel 28 days later. Systemic failures identified: discharge summary failed to meet standards, prescribed medications were not actually dispensed to the patient, pathology alert systems were inadequate, and communication between hospital and primary care physician was poor. Coroner recommended improved discharge summaries, medication dispensing processes, and pathology alert system design.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Hypertensive and ischaemic heart disease
- Superior mesenteric artery occlusion
- Failure to commence recommended antiplatelet therapy (aspirin)
- Deficient discharge summary and medication communication
- Inadequate pathology alert system
- Delayed recognition and escalation of severity
Coroner's recommendations
- Update discharge summary templates to include patient discharge advice encompassing medication changes, follow-up arrangements, and specific instructions about condition changes that should prompt medical review
- Amend policies and procedures to ensure patients discharged on new or altered prescription medication must be provided with a medication supply or prescription with appropriate advice from the prescribing doctor
- Implement a system to alert clinicians to pathology results that require further investigation, designed on human factors principles to maximize alert prominence and proper integration into clinician workflows, with forcing functions such as senior review or documentation of clinical rationale before discharge
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; where a court PDF has technically defective redaction, the hidden text is removed from our archived copy and the full text is withheld. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —