Missed diagnosis of intestinal volvulus in an adult: medico-legal evaluation of a fatal rare disease

A 77-year-old man presented to the Emergency Department with abdominal pain radiating to his back and two episodes of food-related vomiting. Physical examination revealed no signs of acute abdomen, and blood tests showed marked leukocytosis and elevated C-reactive protein (CRP). An abdominal X-ray and CT scan performed five hours later revealed no acute pathology. However, the patient's condition worsened over the next 32 h, and he died without a clinical diagnosis. A judicial autopsy revealed an ileo-jejunal volvulus with necrotic bowel, peritoneal effusion, but no signs of perforation. Histopathological examination confirmed ischemia in the affected intestinal segment. The forensic review of the X-ray and CT scans revealed signs of intestinal obstruction and small bowel volvulus that had not been detected during the hospitalization. The comprehensive analysis of clinical, radiological, autopsy, and histopathological data revealed that septic shock from peritonitis, secondary to volvulus-induced small bowel ischemia, was the cause of death. This case provides an opportunity, within the context of medico-legal liability assessment, to reflect on the influence of cognitive biases that may have contributed to the misdiagnosis. Furthermore, it highlights the role of legal medicine in supporting the systematic investigation of adverse events and in guiding interventions within hospital risk management processes.