Coroner's Finding: WILMAN Joyce Millicent (aka Bracegirdle)

62y · Female·gastric necrosis and perforation due to strangulated diaphragmatic hernia

Joyce Wilman, 62, died from gastric necrosis and perforation due to strangulated para-oesophageal hernia whilst detained under Mental Health Act at Queen Elizabeth Hospital. She presented with vomiting and abdominal pain from 5-8 February 2007. Imaging on 6 February revealed the hernia with recommendation for clinical correlation, but no gastroenterological review occurred despite psychiatric trainee requesting it. Critical delays in specialist consultation meant surgical expertise was unavailable for 24+ hours. Expert evidence indicated that timely gastroenterology review on 7 February would likely have enabled diagnosis and meaningful surgical intervention to prevent death. Coroner found insufficient effort to secure specialist review and delayed delivery of final X-ray reports contributed to preventable death.