Coroner's Finding: Brand, Robin William

62y · Male·Mediastinitis due to perforated oesophagus, with severe emphysema as a contributing factor

A 62-year-old man with severe emphysema and chronic oesophageal stricture died from mediastinitis secondary to perforated oesophagus. He had undergone 46 oesophageal dilations since December 2022, with frequent mucosal tearing documented. Following a dilation procedure on 29 August 2024, he was discharged without signs of perforation. He presented 4 days later with vomiting and chest pain; gastroscopy revealed deep longitudinal tears. The coroner found no fault with the discharge decision, noting the experienced operator and absence of perforation signs post-procedure. The perforation likely resulted from vomiting at home rather than iatrogenic injury. Poor compliance with proton pump inhibitor therapy contributed to his deterioration. No preventability issues were identified.