Finding into death of John Edward Hadland (Millar)

38y · Male·abdominal and chest sepsis complicating iatrogenic left pneumothorax and laparotomy for small bowel obstruction in a man with chromosome 1 short arm deletion syndrome and scoliosis

A 38-year-old man with chromosome 1 short arm deletion syndrome, intellectual disability, and scoliosis died from sepsis following iatrogenic pneumothorax and emergency laparotomy for small bowel obstruction. He was admitted with faecal loading and proctitis, deteriorated with small bowel obstruction requiring emergency surgery. Post-operatively he aspirated, developed aspiration pneumonia and septic shock. During central line insertion for inotrope support, an iatrogenic left pneumotharax occurred. The coroner found the care provided by both community support services and the hospital appropriate. The case highlights challenges in managing complex patients with intellectual disability and limited decision-making capacity in acute emergencies, and the importance of early clarification of medical treatment decision-maker status.