Coronial
NThospital

Inquest into the death of Henry George Wilson aka Albert Wilson

Deceased

Henry George Wilson aka Albert George Wilson

Demographics

77y, male

Date of death

2016-09-19

Finding date

2018-09-21

Cause of death

sepsis due to retroperitoneal collection after biliary stent insertion on a background of colorectal carcinoma with liver metastases causing biliary obstruction

AI-generated summary

A 77-year-old Aboriginal man died from sepsis following a percutaneous transhepatic cholangiography (PTC) procedure that perforated his duodenum. Critical failures included: delayed diagnosis and treatment of peritonitis (diagnosis made at 1.20pm on 18 September, appropriate management delayed until late afternoon); lack of communication with family despite prior assurances; failure to involve family in end-of-life decisions; poor coordination between surgical and interventional radiology teams; and failure to report a clearly reportable death to the coroner (injury-related, unexpected death). The patient died in severe pain with inadequate symptom management. The coroner found management delayed after peritonitis diagnosis but noted this delay unlikely changed outcome. Key lessons: early escalation and investigation of post-procedure complications, urgent sepsis management, family involvement in decisions for elderly patients, inter-professional communication, and proper reporting obligations.

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

Specialties

general surgeryradiologyemergency medicinegastroenterology

Error types

diagnosticcommunicationproceduraldelaysystem

Drugs involved

piperacillin/tazobactamoxycodonefentanyl

Clinical conditions

sepsisduodenal perforationperitonitisretroperitoneal collectionstage 4 colorectal cancerhepatic metastasesbiliary obstructionpost-ercp pancreatitisiatrogenic biliary stent complication

Procedures

open right hemicolectomy with primary anastomosisendoscopic retrograde cholangiopancreatography (ercp)percutaneous transhepatic cholangiography (ptc) with biliary stent insertionpercutaneous drainage attempt

Contributing factors

  • delayed diagnosis of peritoneal perforation
  • delayed institution of appropriate management after diagnosis of peritonitis
  • failure to drain retroperitoneal collection on same day as diagnosis
  • inadequate pain management
  • failure to communicate with family about severity of condition and procedure plans
  • lack of coordination between surgical and interventional radiology teams
  • failure to escalate care appropriately
  • failure to report death to coroner

Coroner's recommendations

  1. Top End Health Service require consultants to fulfil obligations in leading teams, communicating with other treating professionals, communicating with families, and ensuring adverse events are appropriately recorded and reported
  2. Top End Health Service ensure medical staff have training and induction in communicating appropriately with patients and families about symptoms, pain, prognosis, risk of procedures and limits of care
  3. Top End Health Service speak to families after death of a loved one and ensure family have been afforded proper communication, open disclosure and their reasonable needs are being met
  4. Top End Health Service ensure sufficient governance and audit in relation to RiskMan and M&M meetings to ensure they are operating as intended
  5. Top End Health Service ensure all deaths reportable pursuant to Coroners Act are reported in accordance with the law
  6. Change Occurrence of Death/Consent to Autopsy form Part B to require consultant to provide reason why death is not being reported to coroner
  7. Implement one-hour 'pause' the day after a death for team debriefing, paperwork completion and family communication
  8. Implement R.E.A.C.T. system (Recognise, Engage, Ask, Call, Talk) enabling patients and families to escalate concerns
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