Coroner's Finding: ROACH Dawn Ruth
45y · Female·Multi-organ failure due to septicaemia and peritonitis due to faecal leakage fro…
…ss drainage. These deficiencies led to predictable failure. Despite early nursing warning signs (darkening stoma from 6 May), the patient was inappropriately discharged on 11 May 1998 while unwell and unable to manage t…