Coronial
NThospital

Inquest into the death of Souzana Afianos

Deceased

Souzana Afianos

Demographics

41y, female

Date of death

2002-02-21

Finding date

2004-01-16

Cause of death

secondary haemorrhage following gastric banding surgery

AI-generated summary

A 41-year-old enrolled nurse died from secondary haemorrhage eight days after laparoscopic gastric banding surgery in Darwin. She attended ED on 18 February with post-operative pain; Dr McNair discharged her after two hours without contacting her surgeon. She consulted another doctor on 20 February with wound infection but cancelled her surgical appointment. She died 21 February from massive intra-abdominal bleeding from infected necrotic tissue at the band site. The coroner found the surgery was competently performed with no technical fault. The necrosis and subsequent bleeding were not detectable earlier and resulted from normal surgical risks. Key clinical lesson: establish clear protocols requiring routine notification of operating surgeons when post-operative patients attend ED, even when initial assessment seems reassuring. The coroner noted the discharge protocol was ambiguous and inadequate.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general surgeryemergency medicinegeneral practicepathology

Error types

communicationsystem

Drugs involved

paracetamol/codeinesimple panadeinecodeine phosphatelaxative

Clinical conditions

secondary haemorrhagenecrotising soft tissue infectionhypovolaemic shockabdominal pain post-operativewound infection

Procedures

laparoscopic gastric bandingswedish adjustable gastric band placement

Contributing factors

  • failure of ED to contact operating surgeon Dr T. when post-operative patient attended with pain
  • ambiguous and inadequate protocol for notifying treating surgeons in ED
  • necrotic tissue at gastric band site due to normal surgical trauma
  • patient cancelled surgeon appointment on 20 February
  • undetected wound infection

Coroner's recommendations

  1. Rectify ambiguity in Royal Darwin Hospital ED protocol regarding contact of treating surgeons of post-operative patients
  2. Implement routine notification (rather than routine contact) of treating surgeons whenever operative patients attend ED, even when no other action warranted
  3. Establish consultation process between Director of Emergency Medicine and treating surgeons to develop workable protocol accommodating needs of both parties
  4. Methods of notification could include: provision of discharge summary to surgeon, notification at handover, copying notes to surgeon's rooms, email notification, or pigeon-hole system
  5. Review and enhance induction program for overseas-trained doctors at Royal Darwin Hospital to address differences in medical practice between their country of origin and Australia
  6. Specifically address variation in protocols regarding surgeon notification and other aspects of medical practice that may differ from overseas training
Full text
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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.

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