Coronial
SAhospital

Coroner's Finding: DRESCHLER Michelle Lee

Deceased

Michelle Lee Drechsler

Demographics

27y, female

Date of death

1998-04-28

Finding date

2000-07-21

Cause of death

Aspiration of gastric contents associated with persistent vomiting following gastric stapling for morbid obesity

AI-generated summary

A 27-year-old woman died from aspiration of gastric contents following a vertical-banded gastroplasty performed for morbid obesity. The surgeon created a stoma (opening) of 4-5mm diameter using a 27 French bougie, smaller than the 36-38 French standard recommended by most Australian surgeons. This caused severe, persistent vomiting and rapid weight loss over six months. When she presented with syncope and low potassium (2.5), poor communication between her GP and surgeon led to premature discharge without review of critical blood results. She subsequently collapsed at home and aspirated, dying despite resuscitation. Key failures included: the surgeon's use of an inappropriately small bougie without documentation, the GP's failure to formally refer to the surgeon with blood test results, and assumptions about ward coverage that left the patient unseen by either doctor before discharge.

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

Specialties

general surgerygeneral practiceanaesthesiaemergency medicinepathology

Error types

proceduralcommunicationdiagnostic

Drugs involved

diazepammetoclopramideparacetamol/codeine/doxylamineensuresustagen

Clinical conditions

morbid obesityaspiration of gastric contentsgastric outlet obstruction/stenosishypokalaemiasyncopemalnutritionelectrolyte disturbancefatty liver disease

Procedures

vertical-banded gastroplastyendoscopyballoon dilation of gastric outletintubationcardiopulmonary resuscitation

Contributing factors

  • Surgeon created inappropriately small stoma (4-5mm) using 27 French bougie, smaller than standard 36-38 French
  • Surgeon failed to document bougie size used in operation notes
  • Excessive and prolonged vomiting due to outlet obstruction
  • Severe rapid weight loss (58kg in 6 months)
  • Hypokalaemia (potassium 2.5) from chronic vomiting
  • Poor communication between GP and surgeon regarding patient referral
  • GP failed to formally refer patient with abnormal blood results
  • GP made inappropriate assumptions about ward coverage and surgeon's involvement
  • Premature hospital discharge before blood test results were available
  • Syncope/fainting episode on day of discharge
  • Aspiration during subsequent collapse at home

Coroner's recommendations

  1. Dr. Connolly review clinical practices to become familiar with hospital protocols and procedures, particularly pathology tests, admission practices, discharge practices, and referral between practitioners
  2. Mr. Isabel review clinical practice to comply with professionally accepted standards in relation to surgical procedures, referrals from general practitioners (ensuring all medical professionals are aware of assumption of responsibility), and record-keeping (particularly surgical procedure notes)
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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