Learning from errors
Fatal intra-abdominal haemorrhage following percutaneous endoscopic gastrostomy
1 University Hospital of Wales, Department of Histopathology, Heath Park, Cardiff, CF14 4XW, UK
2 University Hospital of Wales, Department of Forensic Medicine, Heath Park, Cardiff, CF14 4XW, UK
3 University Hospital of Wales, Department of Gastroenterology, Heath Park, Cardiff, CF14 4XW, UK
Correspondence to:
Emma Smale, emmalouisesmale{at}hotmail.com
An 83-year-old man was admitted to hospital with a general decline in health, including deteriorating ability to swallow. He was not managing sufficient oral intake to meet his daily nutritional requirements, so had a percutaneous endoscopic gastrostomy (PEG) tube inserted for long-term feeding. Following the procedure he became shocked, and was unresponsive to aggressive fluid resuscitation. He died approximately 7 h after the PEG tube insertion. A postmortem examination revealed 2.5 litres of blood and bloodstained fluid within the abdominal cavity and a haemorrhagic pancreas. Microscopy of the pancreas showed a defect in a small to medium-sized artery, likely to be a branch of the splenic artery. The cause of death (as per section 1 of the death certificate) was (1a) intra-abdominal haemorrhage, (1b) pancreatic trauma at PEG feeding tube insertion and (1c) dysphagia due to cerebrovascular disease.
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