Margaret Pegum, aged 67, died from sepsis following gastric perforation after an intragastric balloon (IGB) procedure for weight loss. She had undergone fundoplication for hiatus hernia in 2012. Despite prior gastric surgery being an absolute contraindication to IGB placement—clearly documented in manufacturer instructions and peer-reviewed literature—Dr Marinos proceeded with the procedure based on assumptions about risk mitigation that were unsupported by evidence. Post-procedure care was also deficient: written discharge instructions created ambiguity about when to seek help, leading to delayed presentation when she developed severe vomiting on 23 June 2015. The coroner found Dr Marinos' decision represented significant error in judgement. Earlier medical contact on 23 June, when symptoms developed, would likely have enhanced her survival chances. The coroner noted no formal recommendations were necessary given Dr Marinos' subsequent practice improvements, but made broader recommendations for professional guidelines and a bariatric outcomes registry.
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Specialties
gastroenterologybariatric surgeryemergency medicinegeneral surgery
Prior gastric surgery (fundoplication) listed as absolute contraindication to IGB but procedure proceeded
Severe vomiting and retching following balloon inflation causing increased intragastric pressure
Intragastric balloon presence reducing stomach space and exacerbating vomiting
Possible role of prior fundoplication altering gastric function and ability to expel gas
Severe dehydration from protracted vomiting prior to hospital presentation
Lack of clarity in post-procedure discharge instructions regarding when to contact physician
Absence of proactive follow-up contact from medical team on 23 June despite high-risk status
Possible scarring and adhesions from prior gastric surgery acting as fixed point during vomiting-induced contractions
Coroner's recommendations
That the Australian and New Zealand Metabolic and Obesity Surgery Society consider developing guidelines concerning intragastric balloon procedures covering patient selection and exclusion criteria, indications and contraindications, risks, and appropriate follow up care and advice.
That the Australian and New Zealand Metabolic and Obesity Surgery Society consider compiling a data registry with details and outcomes for all bariatric patients, aimed at providing clinicians and prospective patients with evidence-based information to guide decisions about the various bariatric options.
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