Coronial
SAhospital

Coroner's Finding: LEONARD Emily Ruth and HILLMAN Glenys Anne

Deceased

Emily Ruth Leonard and Glenys Anne Hillman

Demographics

female

Date of death

2008-11-25

Finding date

2011-08-05

Cause of death

Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perforation of the colon during a laparoscopic gynaecological procedure. Glenys Anne Hillman: hypoxic ischaemic brain injury due to an intracerebral and subdural haemorrhage as a consequence of anticoagulation given to treat a left subclavian vein thrombosis and pulmonary thromboemboli, and peritonitis following perforation of the small bowel during surgery for vaginal prolapse.

AI-generated summary

Two elderly women died following vaginal prolapse surgery performed by the same surgeon, Dr O., with similar mechanisms: bowel perforation leading to peritonitis and sepsis. Mrs Leonard (77) underwent laparoscopic surgery on 30 October 2008; a colon perforation from diathermy-induced injury was not recognized intraoperatively and only became apparent 6 days post-discharge, resulting in multi-organ failure and death. Mrs Hillman (67) underwent open surgery on 28 May 2009; a small bowel perforation was identified and repaired intraoperatively, but the repair failed within 24 hours, leading to contamination, aspiration pneumonia, ARDS, necrotising fasciitis, intracranial bleeding during anticoagulation, and death. Both surgeries involved extensive adhesiolysis. Expert evidence suggested vaginal approaches carried lower bowel injury risk. Key clinical lessons: careful consideration of surgical approach in patients with extensive adhesions; heightened vigilance for early peritonitis signs post-complex abdominal surgery; appropriate drain placement; the importance of formal accreditation and examinations for complex gynaecological surgery rather than reliance on reputation and self-certification.

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

Specialties

gynaecologyintensive caregeneral surgerycolorectal surgeryanaesthesia

Error types

diagnosticproceduraldelay

Drugs involved

heparinanticoagulants

Clinical conditions

vaginal vault prolapsebowel perforationperitonitissepsismulti-organ failurefaecal peritonitisintra-abdominal adhesionsovarian cystsacute respiratory distress syndrome (ards)aspiration pneumonianecrotising fasciitispulmonary thromboembolismsubclavian vein thrombosisintracranial haemorrhagesubdural haemorrhagehypoxic ischaemic brain injuryacute renal failureatrial fibrillationhysterectomy (prior)Crohn's disease (hillman)

Procedures

laparoscopic sacral colpopexylaparoscopic oophorectomyvaginal mesh repairlaparoscopic adhesiolysisopen laparotomybowel repair (enterostomy)bowel resectionhartmann's procedureemergency laparotomycystourethroscopy

Contributing factors

  • Bowel perforation during adhesiolysis in laparoscopic surgery (Leonard)
  • Failure to recognize bowel injury intraoperatively in Leonard case
  • Bowel perforation during open surgery (Hillman)
  • Failure of bowel repair within 24 hours of surgery (Hillman)
  • Delayed diagnosis of bowel perforation in Leonard case (6 days post-discharge)
  • Aspiration of gastric contents during anaesthetic induction for closure of abdominal incision (Hillman)
  • Development of ARDS as complication of aspiration pneumonia (Hillman)
  • Extensive intra-abdominal and pelvic adhesions from previous surgery
  • Use of diathermy for adhesiolysis with potential for delayed bowel injury manifestation
  • Inadequate postoperative monitoring and investigation despite early warning signs in Leonard case
  • Complex abdominal surgical approach chosen despite high adhesion burden when vaginal approach may have been safer
  • Anticoagulation-related intracranial bleeding (Hillman)
  • Surgical blood clots requiring escalation of anticoagulation (Hillman)
  • Necrotising fasciitis of surgical incision (Hillman)

Coroner's recommendations

  1. RANZCOG should consider requiring members and Fellows who perform abdominal vaginal prolapse surgery to demonstrate necessary training, experience, and competence through examination, including proper risk assessment considering adhesions and need for drains, and demonstrating competence in bowel repair
  2. RANZCOG should consider requiring members and Fellows who perform abdominal vaginal prolapse surgery to obtain the Certificate of Urogynaecology from RANZCOG
  3. The Australian Health Practitioner Regulation Agency and the Australian Medical Association (SA) should draw these findings and recommendations to the attention of the wider medical profession
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