Deceased
Nerida Ann Parry
Demographics
63y, female
Coroner
Rinaudo
Date of death
2011-02-06
Finding date
2012-09-06
Cause of death
bile peritonitis as a complication from a laparoscopic cholecystectomy
AI-generated summary
A 63-year-old woman died from bile peritonitis following laparoscopic cholecystectomy. The surgeon's intraoperative management was appropriate with no identified injuries. However, critical clinical deterioration on postoperative day 2 (elevated heart rate 120-135 bpm, hypotension, diaphoresis) was not escalated appropriately by morning nursing staff. When the on-call surgeon was contacted by evening nursing staff with vital signs and ECG findings showing sinus tachycardia, she ordered only IV fluids and analgesia without clinical assessment. The coroner found the surgeon was given specific vital sign observations but failed to adequately assess the clinical picture or escalate care. System failures included poor observation chart documentation and lack of surgical audit by the hospital. Early recognition of postoperative deterioration and appropriate escalation to senior clinical review or higher level of care might have changed the outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (su…
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79y · Female·Dilated cardiomyopathy with decompensated heart failure not appropriately treate…
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