Parry, Nerida Ann
Deceased
Nerida Ann Parry
Demographics
63y, female
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.
Specialties
Error types
Contributing factors
- failure of on-call surgeon to adequately assess vital signs and clinical deterioration
- failure of morning shift nursing staff to escalate deteriorating vital signs to medical staff
- inadequate documentation and recording of observations on clinical charts
- lack of surgical audit and review process for visiting doctors at the hospital
- deficient escalation process for concerning patient signs
Coroner's recommendations
- Refer Dr A.'s conduct to the Australian Health Practitioner Regulation Agency for investigation into professional conduct pursuant to section 49(4) Coroners Act 2003
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