Coronial
QLDhospital

Searle, William Edward

Deceased

William Edward Searle

Demographics

74y, male

Date of death

2019-03-02

Finding date

2023-06-26

Cause of death

Aspiration of gastric contents due to paralytic ileus following Whipple surgery for tubulovillous adenoma of the pancreatic duct

AI-generated summary

William Searle, a 74-year-old prisoner, died from aspiration of gastric contents following a Whipple procedure for recurrent ampullary adenoma. The clinical lessons involve recognition of gastroparesis risk in high-risk patients (diabetes, obesity, opioid use, post-major surgery). Multiple missed opportunities to recognize and manage gastroparesis occurred: on the evening of 1 March when abdominal distension and respiratory distress were attributed to ileus without consideration of NGT reinsertion; at 4:17am on 2 March despite clinical deterioration and abnormal blood work; and after the CTPA showing abdominal/oesophageal distension. Earlier reinsertion of the nasogastric tube, particularly on evening of 1 March, was deemed outcome-changing. The case highlights the importance of close communication between junior and senior staff when patients deviate from expected post-operative recovery parameters, and that ERAS protocols may not suit all high-risk patients including those with poorly controlled diabetes.

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

Specialties

general surgeryintensive careendocrinologyphysiotherapyemergency medicine

Error types

diagnosticcommunicationsystemdelay

Drugs involved

adrenalinemetoclopramideinsulinopioidsamitriptylinelercanidipine

Clinical conditions

ampullary adenomagastroparesisparalytic ileusaspiration pneumoniatype 2 diabetes mellitusobesityascending cholangitisbile duct stricturepost-operative complicationacute respiratory distressacute renal dysfunction

Procedures

whipple procedure (pancreaticoduodenectomy)ERCPnasogastric tube placement and removalCT pulmonary angiogramchest X-rayendotracheal intubationcardiopulmonary resuscitation

Contributing factors

  • gastroparesis (delayed gastric emptying) - recognized complication of Whipple procedure
  • poorly controlled Type 2 diabetes
  • obesity
  • medications contributing to gastroparesis (amitriptyline, lercanidipine, opioids)
  • post-operative ileus
  • abdominal distension not adequately managed
  • failure to recognize gastroparesis and reininsert nasogastric tube
  • inadequate communication of gastroparesis risk
  • inadequate escalation to senior surgical staff
  • early mobilization and free fluids without nasogastric tube in high-risk patient
  • bed restraint limiting repositioning ability

Coroner's recommendations

  1. Enhanced Recovery After Surgery (ERAS) protocol should not be applied to all Whipple patients; consultants must now specify if patients are suitable candidates, with gastroparesis risk due to diabetes, obesity, and immobility being a contraindication
  2. Better communication of gastroparesis risk (17% incidence) to nursing and medical teams
  3. Junior medical officers in HPB Unit now receive education during orientation to ensure consultation between junior and senior treating team members, especially when patient condition is deteriorating
  4. Direct liaison with consultant prior to nasogastric tube removal
  5. External Escorts Custodial Operations Practice Directive (COPD) revised to explicitly state that escorting officers 'must remain vigilant at all times and ensure observations of the prisoner are such that changing circumstances can be responded to at the earliest opportunity to maintain the security and well-being of the prisoner'
  6. Increased focus on recognizing gastroparesis complications post-Whipple, particularly in high-risk patients
  7. Consideration of unique situation of patients in custody with need to balance security and healthcare needs
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