Coronial
QLDhospital

George, Lynda Margaret - Non-inquest findings

Deceased

Lynda Margaret George

Demographics

60y, female

Coroner

McDougall

Date of death

2009-02-05

Finding date

2014-01-31

Cause of death

Peritonitis due to anastomotic leak following subtotal colectomy for treatment of synchronous adenocarcinoma of colon

AI-generated summary

60-year-old woman died from septic shock due to anastomotic leak following subtotal colectomy for synchronous bowel cancers. Early postoperative bronchospasm complicated clinical assessment, leading focus on respiratory rather than abdominal pathology. Leak presented atypically early (day 3 postop) with subtle signs that were missed or misattributed to other causes. Multiple clinicians failed to recognize deterioration or escalate appropriately; ICU involvement was delayed and poorly communicated. Expert review criticized surgical technique (side-to-side vs end-to-end anastomosis), lack of intraoperative air test documentation, and inadequate postoperative monitoring in ICU/HDU setting. However, coroner accepted that presentation was confusing and no single clinician error was pivotal. Systemic failures in recognizing deteriorating patients and escalation were addressed post-incident with implementation of deterioration detection systems and MET team.

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

Specialties

general surgerycolorectal surgeryanaesthesiaintensive caregeneral medicinecardiology

Error types

diagnosticcommunicationsystemdelay

Clinical conditions

synchronous bowel cancer (proximal transverse colon and sigmoid colon)hypertensionchronic obstructive airways diseaseanastomotic leakperitonitisseptic shockintra-abdominal sepsisintraoperative bronchospasmhypoxiametabolic acidosis

Procedures

diagnostic colonoscopyCT scan abdomen pelvissubtotal colectomyileorectal anastomosisgeneral anaesthesia with endotracheal intubation

Contributing factors

  • Anastomotic leak from ileorectal anastomosis
  • Early presentation of anastomotic leak (day 3 postoperatively), atypical for standard teaching
  • Confusing clinical presentation compounded by perioperative bronchospasm
  • Failure to recognize intra-abdominal sepsis early
  • Delayed ICU involvement and poor communication between surgical and ICU teams
  • Lack of consultant-led postoperative care
  • Inadequate postoperative monitoring in ward setting rather than ICU/HDU
  • Undiagnosed chronic obstructive airways disease masking abdominal signs
  • Multiple clinicians focused on respiratory pathology rather than abdominal complications
  • No standardized escalation process for deteriorating patients
  • Absence of Early Warning System implementation at time of incident

Coroner's recommendations

  1. Development of educational package for medical and nursing staff on identification, management and escalation of deteriorating patients
  2. Development of standardized escalation process for deteriorating patients using Early Warning System
  3. Implementation of Q-Adult Deterioration Detection System (Q-ADDs) chart for recognition of deteriorating patients
  4. Implementation of SBAR communication tool for structured clinical information transfer
  5. Establishment of Medical Emergency Team (MET) with defined calling criteria
  6. Implementation of Children's Early Warning Tool (CEWT)
  7. Participation in pilot Emergency Department CEWT
  8. Development of state-wide Maternity Early Warning System
  9. Hospital-wide education program on recognizing deteriorating patients
  10. Nursing-specific education in orientation and simulation sessions
  11. Intern orientation on recognition and management of deteriorating patients
  12. Implementation of state-wide PCA and Epidural monitoring forms
  13. Development of monitoring protocol for patients requiring nursing specials
  14. Development of form for decision-making around MET review and interventions
  15. Improvement of pre-procedure screening of adult surgical patients
  16. Adoption of improved pre-operative assessment form across Queensland Health facilities
  17. Appointment of specialist colorectal surgeon (achieved post-incident)
Full text
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