SAhospital

Coroner's Finding: PRATT Shirley May

Deceased

Shirley May Pratt

Demographics

66y, female

Date of death

2000-07-10

Finding date

2003-05-08

Cause of death

acute necrotising haemorrhagic mediastinitis

AI-generated summary

Mrs Pratt, aged 66, underwent elective gastroscopy at Kapunda Hospital. During the procedure she heaved, and blood was noted at the gastro-oesophageal junction. She was discharged the same afternoon with pain, only to return within hours with pleuritic chest pain and shortness of breath. A perforation of the oesophagus likely occurred during the procedure. The diagnosis of perforated oesophagus was considered but Mrs Pratt was kept at the small rural hospital overnight rather than transferred urgently to the Royal Adelaide Hospital. Transfer occurred next morning but by then mediastinitis had developed with high contamination. Despite surgery, she died from necrotising haemorrhagic mediastinitis with pericardial involvement. The surgeon Mr Gue bore primary responsibility for ensuring appropriate escalation of care. Earlier transfer would have approximately doubled her chances of survival. Key lessons: specialists performing invasive procedures in rural settings must have formal transfer agreements with teaching hospitals, clear emergency protocols, and must take active responsibility for post-operative escalation decisions—not delegate this to inexperienced generalists.

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

Specialties

surgerygeneral surgeryanaesthesiaemergency medicineintensive care

Error types

communicationsystemdelay

Drugs involved

fentanylpropofolmorphineparadexparacetamol/codeine/doxylaminemetronidazolecefotaxime

Clinical conditions

oesophageal perforationmediastinitispleural effusionpericardial effusionhiatus hernianecrotising inflammationsepsis

Procedures

gastroscopyendoscopychest X-raybarium contrast studysurgical exploration and repair of oesophageal perforationthoracotomypleural drainagepericardial drainagegastrostomy insertionjejunostomy insertion

Contributing factors

oesophageal perforation during gastroscopy
failure to transfer patient urgently to major teaching hospital after diagnosis of perforation
delay of approximately 18-24 hours in definitive surgical treatment
extensive contamination of mediastinum during delay
surgeon left rural hospital before complications became apparent
lack of clear communication and escalation protocol between surgeon and general practitioners
friable tissue at perforation site impairing healing

Coroner's recommendations

Where medical specialists perform invasive surgical procedures in rural and remote areas, they should develop appropriate arrangements with a major teaching hospital for emergency evacuation and transfer to that hospital in the event of an emergency
Such specialists should develop a clear and unambiguous emergency plan in the event that they are no longer present in the area where the procedure was carried out after the standard recovery time has elapsed, whereby immediate and effective contact between the general practitioner and the specialist can be established, and an evacuation to a major teaching hospital can be implemented if required
Formal links should be established between endoscopists who perform invasive procedures in rural settings and major teaching hospitals to readily activate communication and transfer processes in emergencies

Full text

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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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