Coroner's Finding: BUTLER Irene

72y · Female·haemorrhage from penetrating duodenal ulcer

A 72-year-old woman collapsed at home and was admitted with black bowel motions (melaena) suggestive of gastrointestinal bleeding. This crucial history was documented by the ED doctor but not properly acted upon by the admitting medical team. Despite a positive faecal occult blood test and clinical evidence of bleeding, no endoscopy was performed. The team attributed symptoms to cardiac pathology based on elevated cardiac enzymes, which expert evidence suggested were misleading due to prolonged immobility. The patient died from massive haemorrhage from a large penetrating duodenal ulcer. The critical failures were: inadequate reassessment of bleeding risk, failure to repeat haemoglobin testing, and not performing indicated endoscopy despite the documented bleeding history. A repeat haemoglobin test might have detected falling levels, and endoscopy would almost certainly have identified and allowed treatment of the bleeding ulcer.