Inquest into the death of David Fensom

67y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to perforated ischaemic bowel

David Fensom, 67, underwent elective fundoplication for hiatus hernia and reflux on 21 September 2010. He developed severe right-sided abdominal pain post-operatively. A laparoscopy on 8 October misinterpreted findings and missed ischaemic bowel—a critical diagnostic error. The expert review identified a 48-hour delay before appropriate laparotomy on 10 October revealed perforated ischaemic bowel with faecal peritonitis and pseudomonal sepsis. While subsequent ICU management was appropriate, the delayed diagnosis of a surgical emergency in a patient with known adhesion history proved fatal. Clinicians should maintain high suspicion for mesenteric ischaemia when severe abdominal pain is disproportionate to examination findings, particularly in patients with prior abdominal surgery. Communication with family was also severely deficient, with no explanation of death provided until eight years later.