Coroner's Finding: Mrs M

Female·multi-organ failure

Mrs M died from multi-organ failure following recurrent intra-abdominal sepsis and surgical complications after endoscopic duodenal perforation in June 2019. During resection of a duodenal adenoma, perforation occurred requiring emergency laparotomy. The surgeon was unable to completely close the perforation. The coroner found that post-perforation management was of appropriate standard, but questioned whether a Whipple procedure should have been performed initially rather than simple resection. Had a Whipple been performed, duodenal perforation would likely have been avoided. However, the decision between approaches was acknowledged as clinically complex, with resection being reasonable given the adenoma's malignant potential and no detected malignancy on biopsy. The clinical lesson emphasizes careful risk-benefit analysis when planning duodenal adenoma resection.