Finding into death of Paul Desmond Smith

58y · Male·complications of large bowel pseudo-obstruction

Paul Desmond Smith, aged 58, died from complications of large bowel pseudo-obstruction following discharge from hospital after inadequate assessment. He had presented to the ED with lower abdominal pain and severe faecal loading (bowel dilation 19cm). Despite a critical admission one year prior requiring ICU and manual disimpaction, and clear risk factors for recurrent obstruction, he was discharged after only symptomatic treatment with laxatives and enema. The morning ward round assessment was cursory, with minimal documentation and no appreciation of his high-risk status. No consideration was given to urinary retention (present on imaging), repeat imaging to confirm improvement, or operative intervention. Key clinical lessons: high-risk patients with recurrent pseudo-obstruction require prolonged inpatient management, not symptom-triggered discharge; previous critical illness should guide conservative decision-making; and comprehensive documentation of clinical reasoning is essential for continuity of safe care.