Inquest into the death of Irene Magriplis

Contributing factors

• inadequate pre-operative investigation and diagnosis of ampullary lesion
• absence of multidisciplinary team review for complex high-risk case
• surgery performed at hospital without resources to mitigate high risks
• inadequate informed consent process; risks not fully disclosed
• patient discouraged from seeking second opinion
• poor post-operative monitoring and documentation
• failure to recognise bile drainage significance (400ml drain fluid not communicated to surgeon)
• failure to recognise septic shock at 7:30am when blood pressure 72/38
• inadequate escalation protocol at Darwin Private Hospital; no Code Blue called
• delayed return to theatre by 16 hours
• poorly resourced High Dependency Unit with inadequate nurse training
• poor communication between medical and nursing staff
• inaccurate fluid balance documentation
• surgeon performing other operations while patient deteriorating

Coroner's recommendations

1. Darwin Private Hospital should not permit high-risk surgery where it does not have resources to mitigate those risks
2. Darwin Private Hospital must implement an escalation system providing proper rapid team response when rapid response criteria are met
3. Darwin Private Hospital should properly resource its High Dependency Unit in conformity with Standard 9 of National Standards on Safety and Quality in Health Care and College of Intensive Care Medicine guidelines
4. Department of Health and Top End Health Service should consider these findings in dealing with and licensing Darwin Private Hospital