Inquest into the death of Margaret Mariani
Deceased
Margaret June Mariani
Demographics
88y, female
Date of death
2019-07-14
Finding date
2025-08-14
Cause of death
Complications of cholecystectomy surgery
AI-generated summary
Margaret Mariani, 88, died from complications of laparoscopic cholecystectomy for gallstone-induced pancreatitis. An iatrogenic small bowel perforation, likely caused by inadvertent suturing during closure, led to peritonitis and aspiration pneumonia. Critical failures in post-operative care at Forster Private Hospital prevented timely diagnosis: inadequate pain monitoring and documentation by RN Martyn, failure to escalate concerning symptoms to the surgeon, poor communication between locum doctor Francis and surgeon Ghaly, and unclear PCA removal procedures. The coroner found signs of peritonitis would have been evident by mid-day 13 July 2019 had the surgeon reviewed the patient or been promptly informed. Timely re-operation could have prevented death. Key lessons: maintain meticulous post-operative documentation, recognize and escalate persistent severe pain as a red flag for complications, ensure direct communication between covering doctors and operating surgeons, and implement robust handover procedures, especially in small private hospitals with minimal staffing.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Iatrogenic small bowel perforation during surgery closure
- Failure to recognise signs of peritonitis
- Inadequate post-operative pain monitoring and documentation
- Failure to escalate patient deterioration to surgeon
- Poor communication between locum doctor and surgeon
- Surgeon did not review patient post-operatively
- Delayed diagnosis of peritonitis
- Aspiration pneumonia secondary to peritonitis and sepsis
- Lack of clarity regarding PCA removal authorisation
Coroner's recommendations
- Forster Private Hospital should provide further training to all staff (VMOs, CMOs/locums and nursing staff) to ensure current policies and procedures are adhered to regarding documentation of patient care
- Forster Private Hospital should amend policies and procedures to ensure greater clarity regarding expectations of VMO being contacted by CMO/locum or nursing staff and in what circumstances
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