Inquest into the death of Rosemarie Campbell

Contributing factors

• small bowel herniation and obstruction post-surgery
• bowel necrosis from strangulation
• aspiration pneumonia from vomiting
• inappropriate discharge despite clinical deterioration
• failure to recognize and escalate signs of bowel obstruction (vomiting, dropping blood pressure and oxygen saturation)
• inadequate communication between nursing staff and surgeon regarding patient condition at discharge
• inadequate pre-operative assessment of reflux symptoms and failure to recommend endoscopy or conservative management

Coroner's recommendations

1. Enhanced training and audit on compliance with vital signs monitoring procedures and proper escalation of concerning findings (particularly Q-AADS scoring) to senior medical and nursing staff
2. Implementation and enforcement of formal discharge criteria for post-operative bariatric surgery patients, including mandatory surgeon review on the day of discharge when complications or clinical concerns are present
3. Continued review and refinement of clinical pathways for bariatric surgical patients with emphasis on recognition of post-operative warning signs
4. Improved patient education on post-operative symptoms, warning signs requiring immediate medical attention, and clear instructions on when to return to hospital