Inquest into the Death of Giovanni Bertoncini

72y · Male·acute gangrene of colon with probable perforation along with bowel obstruction and cardiac failure in a man with insulin dependent diabetes mellitus, severe coronary atherosclerosis and known valvular heart disease

Giovanni Bertoncini, a 72-year-old man with diabetes and cardiac disease, presented to Sir Charles Gairdner Hospital on Christmas Day 2002 with acute abdominal pain and vomiting. Over two days, his condition deteriorated but ischaemic bowel disease was not diagnosed until the afternoon of 27 December, by which time it was too late for surgical intervention. The coroner found that surgical opinion should have been sought on 26 December when the patient's condition was clearly worsening. A clear management plan addressing deterioration, earlier surgical consultation, and consideration of after-hours imaging for potentially life-threatening but undiagnosed conditions could have changed the outcome. The coroner emphasised that ischaemic bowel is a surgical emergency requiring aggressive early management.