A 68-year-old Devonport man who died hours after being discharged from hospital should have been kept for further investigation, a coroner has found.
The man presented to Mersey Community Hospital at 5:09am on September 16, 2023, after experiencing rectal bleeding during the night.
Despite an elevated blood urea level, he was discharged two hours later with haemorrhoid suppositories and an outpatient appointment.
That afternoon, whilst out with a friend, he developed severe abdominal pain and became pale and sweaty. He was found dead in his bed the following morning.
An autopsy revealed the man died from massive blood loss caused by a peptic ulcer that had eroded into an artery in his duodenum.
Coroner Olivia McTaggart found the emergency department clinicians should have considered upper gastrointestinal bleeding as a possible diagnosis and conducted more thorough monitoring.
“The clinicians assessing [the man] in the emergency department should have continued to assess and investigate [him] until a diagnosis was formed,” McTaggart wrote in her findings.
A coronial medical consultant concluded the elevated blood urea should have alerted clinicians to possible upper gastrointestinal bleeding and that observations for haemodynamic instability should have continued.
The coroner noted that bleeding episodes which stop and restart can indicate serious arterial bleeding—exactly what killed the man.
“Very shortly after his discharge, likely that afternoon, [he] suffered a catastrophic arterial bleed,” the coroner found.
“If he had still been in hospital for investigation, the source of the bleeding would have been found with an opportunity for immediate life-saving treatment.”
The health department has accepted the findings and made recommendations including developing guidelines for managing suspected gastrointestinal bleeding.
