Petersen, David Robert

35y · Male·intra-abdominal haemorrhage caused by ruptured spleen

A 35-year-old man with chronic liver disease, cirrhosis, hepatitis C and other comorbidities presented to his GP on 24 January 2007 with acute severe chest pain, profuse sweating, shaking, vomiting and a history of passing black blood per rectum. Examination revealed tachycardia (pulse 160) and hypertension (160/100). The GP diagnosed pleurisy, prescribed analgesics and antimetics, and advised chest X-ray without hospital referral. The patient had a subcapsular splenic haematoma which ruptured 13 hours later causing massive abdominal haemorrhage and death. Critical failings: no vital signs recorded, no abdominal examination performed, no investigation of GI bleeding history, no adequate differential diagnosis, and failure to refer to hospital despite red flag symptoms. Expert evidence indicated hospital referral was the only reasonable course. The coroner found evidence of deliberate falsification of medical records post-mortem to conceal lack of hospital recommendation. Referral made to Medical Board for inadequate care and misconduct.