Inquest into the death of William Edmunds

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

1. Forward brief of evidence, transcript, and findings to the Health Care Complaints Commissioner (HCCC) to investigate Dr Liu-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
2. Implementation of a surgical audit tool to facilitate the capture and recording of data in real time in respect of surgical outcome
3. 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
4. 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