Hamilton, Michael John - Non-inquest findings

72y · Male·Multiple organ failure due to sepsis caused by abdominal adhesions from previous surgery

Michael Hamilton, 72, presented with acute abdominal pain post-bladder surgery while anticoagulated with warfarin. Initial assessment suspected duodenal perforation based on CT findings; laparotomy was performed but found no perforation, only adhesions and possible pancreatitis (lipase 1080 U/L post-op). Key clinical lessons: (1) pre-operative lipase testing was not completed due to insufficient sample—this would have supported pancreatitis diagnosis; (2) patient was discharged from ICU on post-op day 1 despite elevated lipase and pancreatitis indicators; (3) heparin recomenced post-operatively despite increased intra-operative bleeding; (4) these factors may have contributed to subsequent intra-abdominal haematoma requiring multiple re-operations. However, the coroner accepted that complex presentation justified initial management and that ultimate outcome (multi-organ failure from severe pancreatitis and subsequent sepsis from adhesions) would likely have occurred regardless. The case highlights importance of completing all diagnostic tests, maintaining high ICU acuity thresholds, and careful anticoagulation decisions post-operatively.