Coroner's Finding: Hill, James Fredrick

74y · Male·small intestinal ischaemia caused by aortic atherosclerosis

A 74-year-old man presented to hospital with abdominal pain following a fall. He developed hypotension, fever, tachycardia, and elevated inflammatory markers consistent with sepsis within hours of admission. Despite clear warning signs and abnormal blood tests indicating infection and organ dysfunction, a MET call was not made for 18 hours. The underlying ischaemic bowel was not diagnosed until 9pm when he was critically ill with septic shock and multiple organ failure. By then, his entire small intestine was dead and surgery could not save him. Key failures included: not investigating the cause of hypotension, normalising low blood pressure parameters, calling the HMO instead of MET, and failure to transfer to ICU when clinically indicated. Earlier recognition and ICU transfer at 3:30am would have provided a greater chance of survival through timely surgery before complete intestinal necrosis.