Non Inquest Findings TO
Demographics
73y, male
Date of death
2015-11-21
Finding date
2017-10-23
Cause of death
Sepsis (gram-negative septic shock) secondary to complications of selective internal radiation therapy (SIRT) in a patient with previous Whipple procedure
AI-generated summary
A 73-year-old man died from gram-negative septic shock following selective internal radiation therapy (SIRT) for metastatic gastric cancer. He had previously undergone a Whipple procedure in 2014, which creates a direct communication between bowel and bile duct, increasing infection risk. Post-SIRT, he developed fever (37.8°C) and was discharged home on day 2 without antibiotic prophylaxis despite these risk factors. He deteriorated rapidly at home with septic shock and died in hospital despite resuscitation. The interventional radiologist failed to appreciate the significance of the prior Whipple procedure and its associated sepsis risk. Prophylactic antibiotics (ciprofloxacin and metronidazole) before, during and after SIRT would likely have prevented death. Key clinical lesson: when SIRT is performed in post-Whipple patients, prophylactic antibiotic cover is essential to prevent biliary sepsis from gram-negative bacteria colonising the altered biliary tree.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Failure to recognise increased sepsis risk from previous Whipple procedure
- Omission of prophylactic antibiotic cover before, during and after SIRT procedure
- Discharge home with fever (37.8°C) and persistent hypertension without further investigation or referral
- Lack of written institutional protocols for antibiotic prophylaxis in SIRT procedures
- Inadequate post-procedure monitoring and investigation of fever
- Discharge on day 2 post-procedure despite ongoing symptoms
Coroner's recommendations
- Develop written institutional protocols for antibiotic prophylaxis in SIRT procedures, particularly in patients with previous Whipple procedures or other anatomical variations increasing infection risk
- Ensure clinicians performing SIRT are aware of the increased sepsis risk in post-Whipple patients and routinely prescribe prophylactic antibiotics (ciprofloxacin and metronidazole before, during and after procedure)
- Improve post-procedure monitoring and investigation protocols, particularly regarding fever and persistent hypertension post-intervention
- Establish clear criteria for discharge post-SIRT, including investigation and management of fever before discharge
- Ensure adequate physician referral or senior review before discharge in patients with complications or unusual post-procedure symptoms
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