Coroner's Finding: BALLARD Margaret Dawn

76y · Female·aspiration of gastro-intestinal contents as a result of small bowel obstruction due to small bowel torsion

A 76-year-old woman with Alzheimer's dementia and psychiatric illness collapsed on 1 January 2009 and was assessed in the Emergency Department. Dr B. diagnosed vasovagal syncope with gastroenteritis based on the patient's history of diarrhoea and vomiting, and discharged her after 4 hours. However, the patient had actually suffered small bowel torsion causing obstruction, not gastroenteritis. She was not admitted for observation despite the severity of her collapse. On return to the psychiatric facility, she deteriorated with repeated vomiting but no medical review was sought. She aspirated faecal-smelling vomitus and died. Key failures: reliance on potentially unreliable history from a dementia patient, insufficient diagnostic weight given to severe collapse, inadequate observation period, and failure to escalate deterioration at the receiving facility. Vulnerable psychiatric patients require senior clinician review and higher diagnostic suspicion.