Coroner's Finding: Ball, Betty Irene

67y · Female·perforated sigmoid volvulus with peritonitis upon a background of spinocerebellar ataxia

Betty Irene Ball, aged 67, died from perforated sigmoid volvulus with peritonitis on 2 February 2016. She had spinocerebellar ataxia and was resident in aged care. She developed constipation from 15 January 2016, but medical review was not sought until 26 January—11 days later. The coroner found this delay regrettable. Dr S. indicated she would expect notification by day 7 and would have escalated to emergency assessment given Mrs Ball's deteriorating condition. While not definitively preventable, earlier medical attention around day 7 may have resulted in earlier hospital presentation and potentially improved survival. The aged care facility's protocols were inadequate; a new system now provides automatic alerts for bowel inactivity, addressing this systemic weakness.