Coronial
NSWhospital

Inquest into the death of Lesley ARNDELL

Deceased

Lesley Arndell

Demographics

61y, female

Coroner

Decision ofDeputy State Coroner Magistrate Elizabeth Ryan

Date of death

2015-07-06

Finding date

2019-12-19

Cause of death

multi organ failure due to abdominal sepsis

AI-generated summary

Lesley Arndell, aged 61, died from multi-organ failure due to abdominal sepsis after undergoing a Whipple's procedure for pancreatic cancer. Key clinical lessons include: (1) patients with previous bariatric surgery require formal nutritional assessment before major surgery, particularly regarding protein/albumin levels; (2) when sepsis develops post-operatively, antibiotic selection should account for prior antibiotic exposure—Tazocin reuse may have been suboptimal given prior prolonged exposure; (3) medical handover between surgical and ICU teams must explicitly communicate critical medication history; (4) rapid clinical deterioration requires immediate medical review—a 2-hour delay in surgeon arrival without interim medical assessment was substandard; (5) hospital protocols for deteriorating patients must be actively implemented by ward staff and responded to promptly by medical officers. The death likely resulted from anastomotic leak causing peritonitis, compounded by inadequate nutritional optimization and delayed recognition of sepsis.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general surgeryintensive caregastroenterologyendocrinologydieteticsanaesthesia

Error types

medicationcommunicationdelaydiagnostic

Drugs involved

piperacillin/tazobactamvancomycinmeropenemfentanylpethidineoxycodone/naloxonediazepamnoradrenalinevasopressin

Clinical conditions

pancreatic cancercholangitisabdominal sepsisseptic shockhypovolaemic shockmulti-organ failurepancreatic anastomotic leakbiliary peritonitistension pneumothoraxmalnutritionpost-bariatric surgery nutritional deficiency

Procedures

whipple procedurereversal of bilio-pancreatic diversionpercutaneous transhepatic cholecystectomyPTC drain placementintubationmechanical ventilationchest drain insertion for pneumothorax

Contributing factors

  • pancreatic anastomotic leak following Whipple's procedure
  • bacterial cholangitis
  • inadequate nutritional assessment and optimization pre-operatively despite bariatric surgery history
  • failure of medical handover between surgical and ICU teams regarding antibiotic exposure history
  • suboptimal antibiotic selection (Tazocin reuse despite prior prolonged exposure)
  • delay in medical review during acute deterioration on morning of 5 July
  • failure to comply with hospital deteriorating patient protocol
  • development of tension pneumothorax secondary to mechanical ventilation

Coroner's recommendations

  1. Implementing a system whereby every patient with a history of bariatric surgery who is admitted to the Mater Hospital for a serious medical reason or to have major surgery, be referred to a dietitian for nutritional assessment, correction of nutritional deficiencies if present, diet education and monitoring as needed.
  2. Implementing a system whereby all patients transferred to the Mater Hospital from another hospital have a medical admission completed on admission.
Full text
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