Coroner's Court of Western Australia

Inquest into the Death of David Yehuda WEISER

Inquest into the Death of David Yehunda WEISER

Delivered on :18 September 2015

Delivered at : Perth

Finding of : Coroner King

Recommendations :Yes

I recommend that if it is not already doing so, the Western Australian Department of Health, take steps to attempt to identify and have in place a means of giving clinicians in emergency departments timely access to patients’ health information from all sources

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was a 70 year old man who presented at the Peel Health Campus emergency department after feeling unwell and passing a melaena stool.  He was examined by a doctor who was an advanced  trainee in emergency medicine.  The doctor diagnosed a likely infectious gastroenteritis and discharged the deceased home.  The deceased’s condition worsened at home and in the early hours of 13 November 2012 he died from gastrointestinal haemorrhage.

The focus of the inquest was on the quality of the medical care provided to the deceased at the Peel Health Campus emergency department.  The evidence established that the information available to the emergency doctor was sufficient to indicate a gastrointestinal haemorrhage and that there was no basis for the diagnosis of gastroenteritis.  The doctor had sufficient experience to make the correct diagnosis.

The emergency doctor accepted that he should have made the correct diagnosis.  He thought that he had gaps in his knowledge at the relevant time.

As Peel Health Campus is a private hospital, the doctor did not have ready access to the deceased’s medical and pathology records as are available in the public hospital system or from other service providers.   

The Coroner found that the cause of death was gastrointestinal haemorrhage in a man with gastric ulcers and found that death occurred by way of misadventure.

The Coroner noted that the inquest had shed light on the potential for misdiagnosis by emergency doctors and noted  that one means of reducing that potential would be for patients’ health information to be readily available to all emergency departments.  The Coroner made a recommendation to the Health Department to take steps to attempt to make that occur.

Catch Words:  Misdiagnosis : Access to Medical Information : Misadventure: Gastrointestinal Haemorrhage:  Melaena

Last updated: 7-Feb-2024

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