Inquest into the death of Alma June Green

82y · Female·acute peritonitis, ruptured bowel and incarcerated bowel herniation

An 82-year-old woman admitted with bowel obstruction recovered well initially but suffered a preventable fall in the radiology department when left unattended with heavy IV pumps on her wheelchair, fracturing her hip. After hip repair, she developed vomiting on 11 November which was attributed to narcotic medication. Dr H., an intern, examined her twice but did not perform abdominal examination and did not escalate to senior surgical staff. The deceased died from acute peritonitis due to ruptured bowel from her pre-existing incarcerated hernia. While recognition may not have changed outcome (70-80% mortality for bowel rupture in frail elderly), the coroner found concerning gaps: inadequate fall investigation, failure to perform abdominal exam despite new vomiting, and insufficient escalation of family concerns about deterioration. Key lessons: family observations are valuable diagnostic tools; abdominal examination should be performed when presentation suggests possible surgical pathology; and adequate staffing prevents falls in vulnerable populations.