Coronial
NThospital

Inquest into the death of Ali Achmadun Djawas

Deceased

Ali Achmadun Djawas

Demographics

70y, male

Date of death

2017-04-01

Finding date

2019-04-16

Cause of death

multi-organ failure due to septic shock consequent on faecal peritonitis due to anastomotic leak following elective laparoscopic right hemicolectomy

AI-generated summary

Ali Djawas, a 70-year-old Indonesian-born man with comorbidities (hypertension, diabetes, COPD), underwent elective right hemicolectomy on 13 March 2017 for a suspicious ileo-caecal lesion. Biopsies were benign, CT imaging negative, yet surgery proceeded. Critical failures included: inadequate informed consent (risk of death not disclosed despite being material; language barrier ignored; consent form incompletely completed); unnecessary surgery (expert opinion suggests conservative surveillance was appropriate); and catastrophic discharge communication (family not informed of anastomotic leak risk, complications, warning signs, or urgency of return). Post-operative recovery proceeded well until day 6 when he was discharged. On day 10, he developed an anastomotic leak with subsequent septic shock. Late re-admission and emergency surgery could not prevent multi-organ failure. Death was preventable through: (1) appropriate pre-operative decision-making with multidisciplinary team input; (2) proper informed consent with risk disclosure; and (3) comprehensive discharge communication enabling early recognition and return.

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

Specialties

colorectal surgerygeneral surgeryintensive careanaesthesia

Error types

diagnosticcommunicationsystem

Drugs involved

methylnatrexonepiperacillin/tazobactamopioids

Clinical conditions

benign ileo-caecal lesionanastomotic leakfaecal peritonitisseptic shockmulti-organ failurepost-operative ileusatelectasishospital-acquired pneumoniadelirium

Procedures

colonoscopyCT imaginglaparoscopic right hemicolectomylaparotomy

Contributing factors

  • unnecessary elective surgery performed without appropriate multidisciplinary team review of imaging and pathology findings
  • inadequate informed consent - risk of death not disclosed despite being a material risk
  • language barrier not addressed - interpreter services not offered despite English being second language for patient and spouse
  • incomplete consent documentation - consent form not properly completed; interpreter requirement question ignored; risk of death omitted from disclosure section
  • failure to communicate material risks between different treatment options (conservative vs EMR vs hemicolectomy)
  • lack of post-operative communication with family regarding surgical extent and recovery plan
  • grossly inadequate discharge communication - no written discharge summary provided at discharge, no information on anastomotic leak risk or warning signs, no urgency guidance for return to hospital
  • elevated white blood cell count (13.6 and 13.1) pre-discharge not communicated to surgical team - potential warning sign missed
  • delayed identification and management of anastomotic leak - patient did not return to hospital promptly due to lack of understanding of risks

Coroner's recommendations

  1. Top End Health Service ensure appropriate assessment of patient and support person needs for interpreter services prior to discussion of treatment options and procedure risks
  2. Top End Health Service ensure patients are properly informed of risks of procedures, that consent documentation is properly completed, and that compliance is regularly audited
  3. Top End Health Service ensure appropriate communication with patients and supporting family members at discharge, including written discharge summary as minimum
  4. Top End Health Service ensure objective reviews of all deaths arising from elective surgery, considering and recording recommendations for ongoing improvement
Full text
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