Coroner's Finding: Carroll, Terence John

71y · Male·sepsis caused by mediastinal empyema (abscess) which complicated perforation of the oesophagus that occurred during rigid oesophagoscopy

Terence Carroll, 71, died from sepsis and mediastinal empyema following oesophageal perforation during rigid oesophagoscopy for stricture dilation. Critical failures included: CT scan showing suspicious oesophageal thickening was not communicated to the surgeon before the procedure; cancer (adenocarcinoma) was not definitively excluded pre-operatively; diagnosis of perforation was delayed at the referring hospital (22 hours delay from presentation to CTPA confirmation); and the patient was discharged same-day despite being frail, cognitively impaired, hypotensive, and post-operative vital signs indicating instability. The coroner found substandard practice in both the information flow failure and the delayed diagnosis. While oesophageal rupture is a recognised procedural risk and the surgeon was experienced, earlier diagnosis and overnight admission for observation would have enabled timely intervention.