Inquest into the Death of Susan Jessica Elsie WINDIE

22y · Female·bowel obstruction due to faecal impaction

Susan Windie, a 22-year-old with rare congenital abnormalities affecting bowel function, died from bowel obstruction due to faecal impaction complicated by abdominal compartment syndrome. She presented to Carnarvon Hospital on 26 October 2016 with severe constipation. Conservative management with laxatives was attempted with advice from Sir Charles Gairdner Hospital (SCGH). By 28 October, despite worsening pain and clinical deterioration, transfer was not arranged until 28 October evening when her condition became critical. The coroner found the process of rural doctors seeking transfer advice through junior registrars rather than consultants may have delayed recognition of urgency. Clinical lessons: earlier involvement of senior specialists in complex rare presentations; direct consultant access for difficult cases; and lower thresholds for transfer in unusual conditions where standard reassuring signs may be misleading.