Finding into death of Trevor Anthony Peterson

57y · Male·Sepsis from ischemic bowel due to superior mesenteric artery thrombus

Trevor Peterson, a 57-year-old with chronic gut ischemia, underwent mesenteric artery stenting in February 2020. Discharge instructions emphasising dual antiplatelet therapy (DAPT) were not clearly communicated to the vascular team. He self-ceased aspirin before readmission with stent thrombosis in March 2020. Despite initial improvement on heparin, he deteriorated and required emergency surgery with extensive bowel resection. Multiple laparotomies followed with progressive ischemia. He died of sepsis from ischemic bowel. Key learning: ensure explicit communication of critical post-procedural medications between interventional radiologists and treating teams; improve patient education about medication adherence; and consider earlier escalation when pain persists despite apparent clinical improvement. Communication failures between departments and inadequate handover of discharge instructions were contributing factors.