Coroner's Finding: ROACH Dawn Ruth

45y · Female·Multi-organ failure due to septicaemia and peritonitis due to faecal leakage from the large intestine following the failure of a loop colostomy created to deal with a leaking anastomosis following surgery for removal of a carcinoma of the distal sigmoid colon

A 45-year-old woman died from multi-organ failure following failure of a loop colostomy created for management of an anastomotic leak after bowel cancer surgery. The initial anastomotic leak (1.5 cm) was contained and reasonably managed conservatively. However, the colostomy performed on 5 May 1998 was poorly constructed: sited in a deep body fold under tension, with an unsuture bridge, and lacking abscess drainage. These deficiencies led to predictable failure. Despite early nursing warning signs (darkening stoma from 6 May), the patient was inappropriately discharged on 11 May 1998 while unwell and unable to manage the stoma. Within one day, the bridge dislodged, the bowel retracted, and catastrophic peritonitis ensued. The clinical lesson is that colostomy complications identified early (days 1-3 post-op) should trigger prompt revision rather than conservative observation, particularly when there are objective signs of compromise. Discharge decisions require senior surgical oversight, not junior trainee discretion, when patients remain unwell.