Coroner's Finding: Connlley, Maurice Gordon

76y · Male·Extensive small bowel infarction caused by superior mesenteric artery thrombus

A 76-year-old man presented to ED with sudden onset left-sided abdominal pain, vomiting and bowel incontinence. Initial CT imaging was reassuring. However, mesenteric ischaemia—characterised by severe pain without significant clinical signs—was not diagnosed until a CT angiogram performed 19 hours post-presentation revealed superior mesenteric artery thrombosis with acute bowel ischaemia. Critical delays occurred: the diagnosis should have been considered earlier given the clinical presentation; CT angiography should have been ordered sooner; and there was a 3.5-hour delay between oral and written radiology reporting. Despite emergency transfer and multiple surgeries, the patient died from extensive small bowel infarction. The coroner accepted expert opinion that earlier diagnosis would have significantly improved survival chances. Key lessons: maintain high clinical suspicion for mesenteric ischaemia in patients with severe pain disproportionate to examination findings; order appropriate imaging promptly; ensure rapid communication of critical results; escalate diagnostic concerns between teams.