Inquest into the Death of Giovanni Bertoncini

Contributing factors

• failure to diagnose ischaemic bowel until 27 December when too late for surgery
• failure to seek surgical opinion until afternoon of 27 December
• inadequate consideration of ischaemic bowel in differential diagnosis on 26 December despite patient risk factors and deteriorating condition
• lack of clear management plan to guide escalation in event of deterioration
• failure to perform imaging studies on 26 December despite deteriorating condition
• delayed ultrasound examination (ordered 26 December, performed 27 December)
• inadequate pain management
• insufficient regular review despite undiagnosed abdominal pain in Acute Assessment Unit
• small segment of bowel affected resulting in atypical early presentation

Coroner's recommendations

1. Doctors at all levels should be encouraged to write clear plans of management which would include guidance to junior medical and nursing staff, particularly when a clear diagnosis has not been made, as to the action to be taken in the event of unexpected changes in a patient's condition
2. In the case of undiagnosed abdominal pain in relatively elderly patients, the plans should require consideration of urgent surgical review in the event of a patient's condition deteriorating unexpectedly
3. The Health Department should promote awareness of ischaemic bowel and encourage close monitoring of undiagnosed abdominal pain with a view to early detection of the condition
4. Sir Charles Gairdner Hospital should have in place sufficient resources to enable after-hours imaging. When a definite diagnosis cannot be reached and a possible diagnosis which cannot be excluded is potentially life threatening within a short period of time, consideration should be given to ordering after hours imaging
5. In determining the priority to be given to conducting diagnostic tests, consideration should be given not only to diagnoses considered most likely, but also consideration should be given to the consequences which might flow if other diagnoses, which have not been excluded, prove to be correct