Inquest into the death of William Edmunds
Deceased
William John Edmunds
Demographics
79y, male
Date of death
2019-12-02
Finding date
2023-03-09
Cause of death
complications of peritonitis
AI-generated summary
A 79-year-old man with multiple comorbidities presented with a perforated bowel requiring emergency Hartmann's procedure. The operating surgeon, Dr L.-Ming Schmidt, made a catastrophic surgical error by exteriorising the wrong end of bowel as a stoma, causing iatrogenic mechanical bowel obstruction. The error went undetected for 8 days despite clinical signs (absent stomal output, high nasogastric output, abdominal distension). Dr S. failed to order imaging despite concerning clinical features and did not review the patient daily post-operatively, missing opportunities for early detection. Inadequate open disclosure by Dr S. meant the patient and family did not understand the nature of the error. By the time the error was identified, the patient had deteriorated significantly. Multiple subsequent surgeries were required, but the patient ultimately died from complications of peritonitis. The coroner found the surgical error avoidable through appropriate care and attention, and criticised Dr S.'s inadequate post-operative follow-up and failure to arrange timely imaging.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- surgical error in Hartmann's procedure - externalization of wrong end of bowel creating mechanical obstruction
- delay in diagnosis of mechanical bowel obstruction - 8 days between surgery and detection
- inadequate post-operative monitoring and management
- failure to order CT scan despite clinical indicators
- inadequate open disclosure of surgical error
- underlying natural causes including advanced heart failure, COPD, other comorbidities
Coroner's recommendations
- Forward brief of evidence, transcript, and findings to the Health Care Complaints Commissioner (HCCC) to investigate Dr L.-Ming Schmidt's care and treatment of Mr Edmunds between 7 November 2019 - 2 December 2019 at Albury Campus of Albury Wodonga Health to determine whether any disciplinary action is required
- Implementation of a surgical audit tool to facilitate the capture and recording of data in real time in respect of surgical outcome
- Implementation of a policy or directive that mandates the presence of a witness (equal to or more senior than the practitioner who made the error) at the initial disclosure of a medical complication where the disclosure is made by the health practitioner who made the error
- Implementation of a policy or directive which requires, where practicable, that a patient who has experienced an avoidable medical error be informed that they may request that the health practitioner who made the error have no further involvement in their care
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