Inquest into the death of Robert Dalgleish
Deceased
Robert Douglas Dalgleish
Demographics
57y, male
Date of death
2002-07-22
Finding date
2004-02-11
Cause of death
Multiple organ failure in consequence of peritonitis resulting from complications from gastric banding surgery
AI-generated summary
Robert Douglas Dalgleish died from multiple organ failure due to peritonitis resulting from complications of gastric banding surgery. He presented to the ED on 18 July 2002 with abdominal pain and vomiting. Dr B. appropriately assessed him and proposed aspiration of the band and nasogastric tube insertion, but the senior registrar Dr R. deferred intervention until the next morning—an incorrect decision reflecting lack of specialist knowledge. Critical failures occurred on 19 July: the ward round instructions to completely deflate the band were inadequately recorded, Dr B. failed to comply with the deflation instruction and to notify senior staff of this failure. By the time Dr T. was consulted on 20 July, irreversible necrosis of the stomach had developed. Had the band been fully aspirated and nasogastric tube inserted on 18 July, death would likely have been prevented. Key lessons: specialist procedures require specific knowledge among ED staff; critical instructions must be clearly documented; failed clinical interventions must be immediately escalated; junior staff must not silently fail to comply with senior directives.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Failure to fully aspirate gastric band on 18 July 2002
- Failure to insert nasogastric tube on 18 July 2002
- Lack of specialist knowledge of gastric banding complications among ED and surgical staff
- Deferral of band aspiration until following morning on 18 July 2002 despite severe symptoms
- Failure to adequately record ward round instructions on 19 July 2002
- Failure of Dr B. to comply with instruction to aspirate band on 19 July 2002
- Failure of Dr B. to notify senior staff of unsuccessful attempts
- Failure of Dr B. to record his failed attempts in case notes
- Lack of contact with original surgeon Dr T. until 20 July 2002
- Delayed nasogastric tube insertion until 20 July 2002 at 7:50 am
Coroner's recommendations
- Preparation of clinical guidelines for adjustable gastric banding procedures identifying complications, appropriate treatment, and relative urgency of treatment steps, to be developed by RDH Consultants with input from specialists
- Education of RDH staff in relation to specialist procedures where complications are likely to present to the Emergency Department and where non-treatment has severe consequences
- Education of junior medical staff regarding requirements and importance of proper and thorough case note recording as part of normal induction training
- Reminder to all medical staff of the requirement for and importance of proper and thorough noting
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