Maxfield, Annette

Contributing factors

• Inappropriate surgical indication—operation performed for undiagnosed chronic pain rather than malignancy
• Inadequate preoperative psychological assessment and pain management consultation
• Patient selection error; operation attempted despite high risk and unproven benefit
• Unconventional and dangerous surgical technique—perineal-first approach initiated without adequate visualisation
• Inadequate surgeon experience—approximately one APER per year, most recent 2 years prior
• Absence of specialist anaesthetist support for major elective surgery
• Remote hospital setting with limited ICU capabilities
• Inadequate preoperative assessment by anaesthetist—failure to order blood tests, coagulation profile, group and hold, or blood transfusion
• Failure to place arterial line for blood pressure monitoring
• Delayed and inadequate blood product replacement in response to massive haemorrhage
• Delayed ordering of blood tests and coagulation studies after haemorrhage detected
• Failure to draw blood sample before O-negative transfusion, delaying cross-matching
• Inadequate senior anaesthetic supervision during emergency
• Failure of referral anaesthetist to assume leadership role despite worsening condition

Coroner's recommendations

1. Adopt clinical services framework defining which procedures can be performed based on surgeon experience and institutional capacity—currently Mt Isa performs elective open abdominal surgery only for caesarean sections
2. Establish formal mortality and morbidity committee with patient safety officer oversight to investigate adverse events
3. Implement mandatory preoperative assessment protocols for major surgery including blood tests, coagulation profile, and group and hold
4. Require specialist anaesthetic cover for major elective surgery, not provided by general practitioners with part-time anaesthetic duties
5. Establish professional leadership and mentorship in anaesthetics department to ensure compliance with standards of practice
6. Implement mandatory consultation with pain management specialists and psychological assessment before undertaking radical surgery for chronic pain of undetermined aetiology
7. Require clear referral protocols defining where major elective procedures should be performed based on institutional capabilities