Coronial
NThospital

Inquest into the death of Maureen Caroline Thomson

Deceased

Maureen Caroline Thomson

Demographics

58y, female

Date of death

2008-03-27

Finding date

2009-11-24

Cause of death

acute peritonitis, which led to the development of acute septicaemia following abdominal surgery

AI-generated summary

A 58-year-old woman died from acute peritonitis and sepsis following surgery for duodenal diverticulum. Initial elective surgery on 4 March 2008 was technically successful, but the patient deteriorated with suspected common bile duct obstruction requiring revision surgery on 7 March. Despite aggressive management including multiple interventions and ICU support, the patient developed acute liver failure secondary to ischemic hepatitis. The coroner found no evidence of surgical error, inappropriate care, or preventable factors. The deceased fell within the rare but documented mortality risk of duodenal diverticulum surgery. Communication with family was sometimes inconsistent due to rapidly changing clinical conditions, but this reflected genuine clinical uncertainty rather than dishonesty. All clinicians acted with appropriate judgment and provided supportive care throughout.

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

Specialties

general surgerycolorectal surgeryanaesthesiaintensive care

Drugs involved

enoxaparinheparin

Clinical conditions

duodenal diverticulumacute peritonitissepsiscommon bile duct obstructionacute liver failureischaemic hepatitisgangrenous gallbladdermultiple organ failure

Procedures

laparotomy and stapled resection of duodenal diverticulumbiliary bypass (choledochoduodenostomy)placement of feeding tubecholecystectomygastroscopy

Contributing factors

  • probable occlusion to the distal end of the common bile duct
  • acute liver failure secondary to ischemic hepatitis
  • possible thromboembolism affecting hepatic blood supply
  • possible reaction to thromboprophylactic agents (Heparin/Clexane)
  • complex post-operative complications from rare duodenal diverticulum surgery
  • multifactorial thrombosis possibly related to pancreatic involvement, sepsis, or medications
Full text

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