Finding into death of Ross Albert Butler

67y · Male·Faeculent peritonitis due to perforation of a sigmoid volvulus

Ross Butler, a 67-year-old with dementia and Parkinson's disease, presented with abdominal pain and decreased appetite. A sigmoid volvulus was identified and a rectal tube successfully inserted for decompression. Conservative management was continued, but he deteriorated and died from faeculent peritonitis secondary to bowel perforation. Critical clinical lessons include: (1) comprehensive abdominal assessment documentation by nursing staff was inadequate throughout admission; (2) post-procedure imaging results were not effectively communicated between surgical registrars; (3) medical management plans were not clearly documented or communicated to nursing staff or family; (4) vital signs were not recorded during critical overnight period; (5) while the procedure itself was appropriate, better imaging interpretation and family communication about the persistent volvulus could have facilitated earlier end-of-life discussions given his significant comorbidities.