Deceased
Jodie Pearson - Findings - 01 March 2019.docx Final version
Demographics
47y, female
Date of death
2016-02-19
Finding date
2019
Cause of death
hypoxic encephalopathy and aspiration pneumonia following aspiration of gastric contents during gastroscopy procedure
AI-generated summary
Jodie Ann Pearson, aged 47, died from hypoxic encephalopathy and aspiration pneumonia following aspiration of gastric contents during a gastroscopy at Belmont Hospital on 15 February 2016. Critical pre-procedure information—a GP referral letter and CT scan showing massive gastric distension with food residue—was not communicated to the surgeon Dr. Gani before the procedure commenced. Inexperienced junior doctor Dr. Luu received the documents from nursing staff but failed to effectively convey them to the surgeon, misinterpreting the letter as routine. The procedure proceeded despite clear evidence the patient had a full stomach, causing aspiration during instrument withdrawal and respiratory arrest. The coroner found the death preventable through proper communication protocols. Key clinical lessons: establish clear handover procedures with assigned responsibility; communicate all critical pre-procedure information to senior clinicians; thoroughly review all available clinical data before proceeding; do not rely on limited pre-procedure questioning alone for complex patients.
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Specialties
Error types
Clinical conditions
Procedures
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