Deceased
Christopher Glen Essery
Demographics
74y, male
Coroner
Gallagher
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 Gourlas) 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.
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Specialties
Error types
Clinical conditions
Procedures
73y · Female·Multiple organ failure due to or as a consequence of sepsis due to or as a conse…
73-year-old woman died 12 days after elective colorectal surgery for synchronous caecal and rectal tumours. Post-operatively, she developed persistent low urine output and intermittent hypotension managed with repeated f…
87y · Male·Strangulated small bowel due to adhesions from previous abdominal surgery
An 87-year-old man with diabetes, hypertension and dementia was admitted with presumed UTI and dehydration. Within 24 hours, nursing staff observed a distended abdomen and bile-stained vomiting—clinical signs of bowel ob…
60y · Female·Peritonitis due to anastomotic leak following subtotal colectomy for treatment o…
60-year-old woman died from septic shock due to anastomotic leak following subtotal colectomy for synchronous bowel cancers. Early postoperative bronchospasm complicated clinical assessment, leading focus on respiratory …
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