Coroner's Finding: de-identified RS

68y · Male·Exsanguination due to peptic ulcer of the duodenum with erosion into the gastroduodenal artery

A 68-year-old man presented to the emergency department with two episodes of fresh rectal bleeding and elevated blood urea. Despite stable vital signs, he was discharged after two hours with haemorrhoid suppositories and an outpatient appointment, without formal diagnosis or investigation. The coroner found that clinicians should have considered upper gastrointestinal bleeding as a differential diagnosis, particularly given the elevated urea and characteristic pattern of bleeding that stops then recurs. They should have assessed for haemodynamic instability and undertaken further investigations before discharge. The patient died that afternoon from exsanguination due to a bleeding duodenal ulcer eroding into the gastroduodenal artery. The coroner concluded that if the patient had remained in hospital for investigation, the bleeding source would have been identified, allowing life-saving treatment. Key lessons include maintaining diagnostic rigour, considering differential diagnoses systematically, and not discharging patients without established diagnoses.