Beverly ann murphy finding & recommendations 0701 08

Contributing factors

• Wound dehiscence following hysterectomy
• Iatrogenic small bowel perforations during initial and repeat surgery
• Bowel obstruction not promptly recognized on radiological imaging
• Delayed return to theatre (6 days post-op)
• Bowel perforations not identified before closing patient on 12 April
• Delayed colorectal surgical consultation
• Post-operative sepsis and fistula formation
• Inadequate availability of appropriate tracheostomy tube size (systems failure)
• Tracheostomy tube dislodgment during patient turning
• Delayed recognition of airway compromise by nursing staff
• Failure to immediately seek medical assistance for respiratory distress
• Repeated failed airway procedures before definitive management by ICU team
• Prolonged hypoxia of 20-30 minutes duration
• Obesity complicating airway management
• Pre-existing cardiomegaly and multiple co-morbidities

Coroner's recommendations

1. The Royal College of Surgeons and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists should consider introducing a mandatory training requirement for postgraduate certification in Gynaecological Oncology requiring participation in the work of a general surgical unit, particularly in areas of gastrointestinal and urological surgery, for a minimum of twelve months