Finding patience,iandonald 970 07
Deceased
Ian Donald Patience
Demographics
68y, male
Date of death
2007-06-10
Finding date
2010-12-22
Cause of death
Complications following colon surgery on a background of cirrhosis of the liver; specifically anastomotic leak leading to sepsis, hepatic encephalopathy, and multi-organ failure
AI-generated summary
Ian Donald Patience, 68, died on 10 June 2007 from complications following colon surgery in the setting of cirrhosis. He underwent right hemicolectomy at Sydney South West Private Hospital on 31 May 2007 for colorectal cancer. Post-operatively, he developed massive ascites and hepatic encephalopathy. Key clinical lessons: cirrhosis severity was not adequately assessed or communicated to all treating clinicians; performing high-risk surgery at a small private hospital without specialist gastroenterological support or ICU was inappropriate; post-operative fluid management was inadequate (excess saline given when sodium restriction was needed); gastroenterological input was not sought early; and transfer to specialist care should have occurred earlier when complications became apparent. An anastomotic leak required emergency surgery on 9 June, but by then multi-organ failure had developed. The coroner recommended comprehensive guidelines for perioperative assessment and management of cirrhotic surgical patients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Inadequate assessment and communication of cirrhosis severity pre-operatively
- Failure to communicate cirrhosis diagnosis to all post-operative treating clinicians
- Decision to perform high-risk surgery at small private hospital without specialist gastroenterological or intensive care facilities
- Inadequate post-operative fluid management with excess sodium administration
- Delayed or absent gastroenterological consultation post-operatively
- Delayed recognition of hepatic encephalopathy
- Delayed transfer to hospital with specialist facilities
- Underestimation of operative risk in cirrhotic patient
Coroner's recommendations
- Require that a copy of any operation notes made by a surgeon be placed in relevant hospital records as soon as practicable following the operation
- Formulate comprehensive guidelines for assessment and management of cirrhotic patients undergoing surgery
- Undertake or sponsor a study of where medium- and high-risk surgery on cirrhotic patients should be performed and what facilities ought to be available for post-operative care by Child-Pugh category
- Guidelines should address: optimal risk assessment system for cirrhotic patients (Child-Pugh vs alternatives); reclassification procedures if post-operative decompensation occurs; appropriate location for medium- and high-risk operations (high-volume hospitals with gastroenterological support preferred); required facilities for post-operative care; timing of specialist gastroenterological or physician review post-operatively (within 48-72 hours or when clinically needed); appropriate fluid balance regime for post-operative ascites (sodium restriction, saline limitation, albumin use decisions); clinically significant signs of liver failure or decompensation to monitor; informed consent discussions regarding specific increased mortality and morbidity risks for cirrhotic patients; and development of post-operative care checklists for cirrhotic patients undergoing medium- to high-risk surgery
- Guidelines for post-operative management of cirrhotic patients should include strong reminder to clinicians to pay close attention to concerns raised by family members about adverse changes in the patient's condition
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