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Coroner's Finding: Baldock, Andrea Eileen

Deceased

Andrea Eileen Baldock

Demographics

46y, female

Date of death

2016-09-07

Finding date

2017-06-16

Cause of death

combined effects of aspiration pneumonia due to gastroparesis following sleeve gastrectomy and ischaemic heart disease with cardiomegaly

AI-generated summary

A 46-year-old woman died from aspiration pneumonia due to gastroparesis following sleeve gastrectomy, complicated by ischaemic heart disease. Post-operative recovery was beset with persistent vomiting, dehydration, and electrolyte disturbances from 10 May onwards. Despite multiple presentations to hospital and general practice over three months, management was described as ad hoc, unstructured, and largely unmonitored without direct supervision. The patient experienced recurrent episodes of ventricular tachycardia and ultimately aspirated food into her lungs. While gastroparesis is a recognised but uncommon complication of sleeve gastrectomy, the coroner identified failure to implement a structured, closely monitored post-operative care plan as a significant deficiency. The case illustrates that weight reduction surgery carries non-trivial risks and should follow exhaustion of non-invasive options.

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

Specialties

general surgerygastroenterologycardiologyanaesthesiageneral practicedietetics

Error types

systemdelay

Clinical conditions

gastroparesisaspiration pneumoniaacute on chronic aspiration pneumoniaischaemic heart diseasecardiomegalyhypokalaemiahypomagnesaemiametabolic alkalosisacute renal failureventricular tachycardiaatrial fibrillationmalnutritiondehydrationbronchopneumoniatype 2 diabetes mellitushypertensionobesity

Procedures

laparoscopic sleeve gastrectomygastrograffin swallowbarium meal follow-throughgastroscopynaso-duodenal feeding tube insertionnaso-gastric tube insertiongastric bypass surgery (planned but not completed)

Contributing factors

  • gastroparesis as complication of sleeve gastrectomy
  • persistent vomiting and reduced oral intake
  • severe dehydration and electrolyte disturbance (hypokalaemia, hypomagnesaemia)
  • metabolic alkalosis and acute renal failure
  • recurrent episodes of ventricular tachycardia and atrial fibrillation
  • aspiration of food/gastric contents into lungs
  • bronchopneumonia/aspiration pneumonia
  • malnutrition and weight loss (47 kg post-surgery)
  • ischaemic heart disease with cardiomegaly
  • unstructured and ad hoc post-operative management without direct supervision

Coroner's recommendations

  1. The LGH should conduct a review of its practices surrounding post-operative care of weight reduction patients with a view to implementing a structured and closely monitored plan designed to maximise prospects of patient recovery, particularly in instances where post-surgical complications arise
  2. Weight reduction surgery should not be lightly embarked upon and should only follow exhaustion of all suitable non-invasive options
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