Non-inquest findings into the death of Mr H.

89y · Male·combination of biochemical consequences of colonic pseudo-obstruction and faecal loading, on a background of atherosclerotic and cardiovascular disease

An 89-year-old man with multiple comorbidities including previous colon cancer died from faecal impaction and stercoral colitis. He resided in a residential aged care facility (RACF) where staff failed to recognize that small bowel movements represented faecal overflow rather than normal bowel function. Despite bowel charts documenting 24 days without significant bowel opening, nursing and medical staff did not escalate care or adequately assess his abdomen after 4 March 2022. He was on opioid analgesia and medications causing constipation, but laxative regimens were inadequate. When he deteriorated acutely with bowel obstruction symptoms, CT imaging revealed severe impaction with stercoral colitis and perforation risk. The coroner found missed opportunities for escalation of constipation management between 4-27 March 2022, poor recognition of faecal overflow patterns, lack of abdominal assessment, and unclear medical escalation pathways contributed to his death.