NThospital

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 Bodnar appropriately assessed him and proposed aspiration of the band and nasogastric tube insertion, but the senior registrar Dr Read 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 Boldery failed to comply with the deflation instruction and to notify senior staff of this failure. By the time Dr Treacy 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. Report an inaccuracy.

Specialties

surgerygeneral surgeryemergency medicineintensive care

Error types

diagnosticcommunicationsystemdelay

Clinical conditions

gastric band obstructiongastric necrosisperitonitisseptic shockgastrointestinal obstructiongastric infarctionhiatus hernia

Procedures

gastric bandingband aspirationnasogastric tube insertionlaparotomygastrectomy

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 Boldery to comply with instruction to aspirate band on 19 July 2002
Failure of Dr Boldery to notify senior staff of unsuccessful attempts
Failure of Dr Boldery to record his failed attempts in case notes
Lack of contact with original surgeon Dr Treacy 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

Full text

Official source Archived copy

Related cases from NT

NThospital2026-01-09

Inquest into the death of C Guyula

49y · Female·Hypoxia due to complications following incision and drainage of a right buttock …

A 48-year-old woman with multiple comorbidities (diabetes, COPD, chronic kidney disease, ischaemic heart disease) died following complications of anaesthesia during incision and drainage of a buttock abscess. Critical fa…

anaesthesiasurgeryproceduralmedicationfentanyl

NThospital2012-10-29

Inquest into the death of Ben James Witham

17y · Male·Multi-organ failure with terminal fungal sepsis (Aspergillus) on a background of…

Ben Witham, a 17-year-old with acute lymphoblastic leukaemia, died from multi-organ failure with terminal fungal sepsis. The critical issue identified was a substantial delay in investigating acute severe abdominal pain …

oncologyhaematologydiagnosticdelaymorphine

NThome2010-10-29

Inquest into the death of Kristelle Ruby Mulladad aka Oliver

16y · Female·obstructed breathing and heart arrhythmia secondary to severe obstructive sleep …

A 16-year-old Aboriginal girl with severe obstructive sleep apnoea died unexpectedly in her home one week before scheduled surgery. She had been symptomatic since age 13, but surgery was delayed for four years due to mul…

ENT surgerygeneral practicediagnosticcommunication

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.