QLDhospital

Tang, Shannon Sheng Wen

Deceased

Shannon Sheng Wen Tang

Demographics

21y, male

Coroner

Clements

Date of death

2003-06-05

Finding date

2007-08-10

Cause of death

multi-organ failure due to septicaemia of mixed respiratory (bronchopneumonia) and intra-abdominal (subhepatic abscess) origin

AI-generated summary

Shannon Tang, a 21-year-old from Singapore with severe obesity (BMI 52) and multiple comorbidities including sleep apnoea, underwent elective laparoscopic gastric bypass surgery performed by Dr F.. He died on day 7 post-operatively from multi-organ failure due to sepsis of mixed respiratory and intra-abdominal origin. Critical issues include: inadequate pre-operative assessment and risk discussion (first face-to-face consultation was 20 minutes on surgery day); failure to clearly communicate to intensive care staff that pre-operative assessment was required; post-operative complications including a subhepatic abscess (undiscovered until autopsy due to large liver and deep location) and bronchopneumonia; a 6-hour period of endotracheal tube cuff leak increasing aspiration risk; and unclear documentation of clinical decisions. The coroner found the preponderance of expert opinion favoured respiratory rather than intra-abdominal sepsis as the primary source. No critical single event was identified as directly causing death, but cumulative factors including inadequate pre-operative counselling and assessment contributed to preventable harm.

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Specialties

bariatric surgerygeneral surgeryintensive careanaesthesiainfectious diseasespathology

Error types

communicationdiagnosticsystemdelayprocedural

Drugs involved

vancomycinticarcillin/clavulanatemetronidazolecefalexinmeropenemfluconazole

Clinical conditions

severe obesitysleep apnoeahypertensionfatty liver diseasehyperlipidaemiaproteinuriadepressionpost-operative sepsisbronchopneumoniasubhepatic abscessmulti-organ failureupper lobe atelectasisbowel obstruction (post-operative adhesion)acute kidney injury

Procedures

laparoscopic gastric bypass surgerylaparoscopic exploration (first revision)open laparotomy (conversion)laparoscopic exploration (second revision)open laparotomy (third exploration)endotracheal intubationcentral line insertion

Contributing factors

inadequate pre-operative face-to-face consultation (20 minutes on day of surgery)
insufficient informed consent discussion regarding mortality risk
failure to provide specific written assessment request to intensive care staff
surgeon did not physically examine patient pre-operatively
large fatty liver obscuring surgical complications
post-operative subhepatic abscess formation (undetected until autopsy)
development of bronchopneumonia in immediate post-operative period
endotracheal tube cuff leak for 6 hours (6am-7pm on 4 June) increasing aspiration risk
radiological imaging limitations due to supine positioning in ICU
lack of nasogastric tube decompression
difficulty managing pain and sedation balance
delayed recognition and treatment of evolving sepsis
patient immobility contributing to atelectasis and pneumonia risk

Coroner's recommendations

Relevant specialist colleges and/or hospitals consider and review a requirement for face-to-face consultation between patient and surgeon and the appropriate minimum period prior to the proposed surgery for such consultation
Relevant hospitals and/or specialist colleges consider and review the level of specific information about risk of mortality in forms of consent to be signed by a patient prior to treatment
If a surgeon is relying on an assessment being made by intensive care staff pre-operatively of a patient's suitability for surgery, the surgeon should provide specific written communication of such request accompanied by the patient's relevant medical history to the intensive care staff

Full text

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Source and disclaimer

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