Coronial
QLDhospital

Plumb, Mark Anthony

Deceased

Mark Anthony Plumb

Demographics

76y, male

Date of death

2014-10-23

Finding date

2016-08-19

Cause of death

Multiple organ failure due to sepsis with peritonitis and pancreatitis, secondary to perforation of the junction of common bile duct, pancreatic duct and duodenum

AI-generated summary

A 76-year-old man died from multiple organ failure following an ERCP procedure for gallstone removal. The procedure itself was appropriate and uneventful. Post-operatively, he developed severe abdominal pain and a CT scan at 21:25 revealed suspected perforation of the common bile duct/duodenum with free abdominal fluid. The surgeon opted for conservative management without reviewing the patient or escalating care. Deterioration continued overnight with peritonitis developing. A second review at 02:15 identified clinical deterioration but the surgeon was not contacted until 05:30, causing 11-16 hour delay in transfer to a specialist centre. By arrival at Wesley Hospital, sepsis and multi-organ failure were established. Earlier recognition of the CT findings, physical review by the surgeon post-scan, escalation of clinical concerns to the surgeon at 02:15, and timely transfer to a specialist unit would likely have improved outcomes.

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

Specialties

surgeryanaesthesiaintensive caregastroenterologyradiology

Error types

diagnosticcommunicationdelaysystem

Drugs involved

morphineparacetamoliv fluidsantibioticsmetoclopramidehyoscine butylbromidefentanylalbumininotropic agents

Clinical conditions

perforation of common bile ductperforation of pancreatic ductperforation of duodenumperitonitispancreatitissepsisacute renal failurebiliary sepsismulti-organ failuresystemic inflammatory response syndrome

Procedures

endoscopic retrograde cholangiopancreatographysphincterotomycatheter insertionCT scanblood investigationsexploratory laparotomyperitoneal washout

Contributing factors

  • Failure to physically review patient after critical CT scan findings at 21:25
  • Failure to escalate to specialist care despite CT evidence of perforation
  • Conservative management approach without contingency planning
  • Breakdown in communication between nursing staff and surgeon regarding deterioration at 02:15
  • Delayed notification to surgeon of clinical deterioration
  • Inadequate documentation of clinical reviews and management plans
  • Delay in transfer to specialist centre (11-16 hours from clinical deterioration)
  • Staffing limitations in CCU affecting patient transfer decisions
  • Lack of early escalation protocol for deteriorating post-operative patients

Coroner's recommendations

  1. Ensure peri-operative cholangiograms are reviewed by radiologist and reported to surgeon immediately
  2. Schedule ERCPs with radiologist consultation, particularly for emergency out-of-hours procedures
  3. Implement policy that unresolved pain post-ERCP receives timely CT scan with immediate reporting to surgeon
  4. Develop and adjust tools to provide greater clarity and triggers for action in management of deteriorating patients
  5. Enforce mandatory communication to Director of CCU or Hospital Nurse Unit Manager regarding deteriorating patients to determine resource availability
  6. Review level of ERCP procedures to maintain surgeon competency
  7. Improve pain management policy awareness and implementation across hospital
  8. Update track-and-trigger observation charts to provide greater clarity on triggers and required responses
  9. Revise Recognising and Responding to Clinical Deterioration Policy with enhanced education
  10. Ensure all intra-hospital transfers are timely and appropriate
  11. Implement Patient Communication Board in each room to improve team communication
  12. Develop training plan for resident medical officers on role expectations and clinical competency
  13. Ensure Root Cause Analysis processes include relevant members of treating team
  14. Enhance consent forms to detail specific risks and complications of procedures
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