Inquest into the death of Christopher Glen Essery
Deceased
Christopher Glen Essery
Demographics
74y, male
Date of death
2019-02-20
Finding date
2025-06-20
Cause of death
Sepsis secondary to fistulating Crohn's disease and post-surgery complications following surgical treatment on 24 January 2019
AI-generated summary
Christopher Essery, a 74-year-old man with complex fistulating Crohn's disease, died from sepsis following surgery on 24 January 2019. He was transferred to Princess Alexandra Hospital (PAH) on 31 August 2018 for specialist management of enterocutaneous fistulas and intra-abdominal collections. Critical systemic failures occurred: (1) no early post-admission colorectal surgical consultant review despite this being the stated purpose of transfer; (2) the assigned surgeon (Dr G.) went on extended leave without reviewing the patient or formally handing over care; (3) no single consultant took responsibility for his care during 12 weeks of absence, creating confusion about accountability; (4) medical optimisation was prolonged without review of previous unsuccessful optimisation at Cairns; (5) a secondarily-infected mesh from previous hernia repair was not recognised or considered in management decisions despite radiological evidence. These failures delayed definitive surgical consideration and contributed to progressive clinical deterioration. Clinicians should ensure formal handover and continuity of care for complex patients when extended leave is planned, and should review prior treatment failures before commencing similar interventions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- failure to conduct early post-admission colorectal surgical consultant review
- treating surgeon went on extended leave without reviewing patient
- lack of formal handover of patient care to another consultant
- rotating roster system created confusion about responsibility and continuity of care
- prolonged attempted medical optimisation without review of previous failed optimisation at Cairns
- secondarily infected mesh from previous hernia repair not recognised or considered in management
- delayed definitive surgical consideration due to systems failures
- progressive clinical deterioration during extended period of optimisation
- no single consultant took ownership of care during extended leave period
Coroner's recommendations
- MSHHS should review and consider changing any existing protocols for consultant coverage on a rotating roster basis in the Colorectal Ward or IBD Clinic at PAH which creates a risk of not providing effective continuity of care for patients during periods of extended leave of the patient's admitting or treating consultant
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