QLDhospital

Searle, William Edward

Deceased

William Edward Searle

Demographics

74y, male

Coroner

Ryan

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. Report an inaccuracy.

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

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
Better communication of gastroparesis risk (17% incidence) to nursing and medical teams
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
Direct liaison with consultant prior to nasogastric tube removal
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'
Increased focus on recognizing gastroparesis complications post-Whipple, particularly in high-risk patients
Consideration of unique situation of patients in custody with need to balance security and healthcare needs

Full text

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