Coroner's Finding: SORENSEN Ruth Bengta Maria

69y · Female·faecal peritonitis due to small bowel obstruction and perforation due to peritoneal adhesions

A 69-year-old woman presented to the Emergency Department with abdominal pain and vomiting. The doctor did not take adequate history, perform thorough physical examination, or order basic investigations including blood tests or abdominal X-ray. She was discharged after 2 hours 40 minutes without diagnosis. She deteriorated rapidly and died at home the next morning from faecal peritonitis due to small bowel obstruction and perforation from peritoneal adhesions. The coroner found the standard of care was seriously inadequate. Critical lessons: elderly patients with undiagnosed abdominal pain require low threshold for admission, basic investigations (FBC, urea/electrolytes, abdominal X-ray), careful history including surgical history, attention to abnormal vital signs, and high index of suspicion to avoid premature diagnostic closure with 'gastroenteritis' diagnosis.