Coronial
QLDhospital

McNaught, Judith

Deceased

Judith Anne McNaught

Demographics

69y, female

Coroner

Hennessy

Date of death

2010-06-06

Finding date

2012-12-06

Cause of death

Septic shock due to biliary peritonitis as a consequence of laparoscopic cholecystectomy

AI-generated summary

A 69-year-old woman died of septic shock following bile leak complications after laparoscopic cholecystectomy. Critical failures included: (1) inappropriate transfer to low-dependency unit on post-op day 1 despite consultant's undocumented concerns; (2) failure to initiate antibiotics at ward round despite sepsis indicators; (3) delayed surgical response despite documented critical illness; (4) poor communication between surgical team, with provisional diagnoses and operative plans not documented or communicated; (5) incomplete handover of antibiotic administration status to theatre; (6) inadequate nursing care with missed vital signs and failure to escalate MEWS score of 3. Expert evidence confirmed antibiotics initiated immediately post-diagnosis would have reduced mortality risk. Systemic failures included bed management prioritizing resource efficiency over patient safety, inadequate intern supervision, poor documentation, and deficient root cause analysis that failed to interview treating clinicians.

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

Specialties

surgeryanaesthesiaintensive careemergency medicine

Error types

diagnosticmedicationcommunicationsystemdelay

Drugs involved

morphinemetronidazoleampicillingentamicinfentanyl

Clinical conditions

bile leakperitonitisseptic shocksepsismulti-organ failurehepatic ischaemiabowel ischaemiahypotensiontachycardiarenal failure

Procedures

laparoscopic cholecystectomyERCP with sphincterotomyMRCPCT scan with contrastabdominal X-rayre-laparotomyendotracheal intubationarterial line insertioncentral line insertionurinary catheter insertionnasogastric tube insertion

Contributing factors

  • bile leak from cystic duct following laparoscopic cholecystectomy
  • inappropriate transfer to low-dependency rehabilitation unit on post-operative day 1
  • failure to initiate antibiotics at ward round despite sepsis diagnosis
  • delayed surgical intervention
  • poor documentation of provisional diagnoses and operative plans
  • undocumented consultant concerns not communicated to nursing staff
  • incomplete handover of antibiotic administration status to operating theatre
  • lack of regular vital sign monitoring in rehabilitation unit
  • failure to escalate MEWS score of 3
  • inadequate supervision of junior doctors
  • breakdown in multi-disciplinary team communication
  • ad hoc allocation of clinical responsibilities
  • incomplete antibiotic administration prior to surgery
  • infected bile in abdomen (likely from prior ERCP sphincterotomy allowing retrograde duodenal contamination)

Coroner's recommendations

  1. Rockhampton Hospital should seriously consider allocation of resources for dedicated discharge planners in major acute wards, with additional nursing resources to replace nurses performing discharge planning duties
  2. Rockhampton Hospital should seriously consider whether patient outlie system is necessary and appropriate for acute and post-surgical patients
  3. If patient outlie for acute/post-surgical patients must continue, conduct complete review of system including: patient reviews before transfer, appropriate and complete handover, detailed nursing care plans, consultation with treating doctors before transfer, consultation with supervisors of sending and receiving wards, and regular reviews of appropriateness of continued placement
  4. Rockhampton Hospital should ensure all relevant care providers are interviewed in Root Cause Analyses investigations, with statutory privilege protection to enable open discussion and early identification of issues
  5. Issue of drain placement in laparoscopic cholecystectomy to be referred to Royal Australasian College of Surgeons for ongoing review and debate
Full text
Official source Archived copy

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