Coronial
TAShospital

Coroner's Finding: Russell; Patricia Joy

Deceased

Patricia Joy Russell

Demographics

74y, female

Date of death

2017-01-19

Finding date

2018-03-26

Cause of death

empyema/sepsis complicating oesophageal perforation following a complicated elective hernia repair

AI-generated summary

Mrs Russell, a 74-year-old woman with diabetes, obesity, COPD and coronary disease, underwent elective hernia repair in November 2016 at a regional hospital. An unexpected colon tumour was removed during surgery. She subsequently developed a faecal leak from the colon anastomosis requiring surgical repair. Critically, she also suffered a spontaneous oesophageal perforation (Boerhaave syndrome) likely on 6-7 November, but this diagnosis was not made until 13 November—a six-day delay. The perforated oesophagus led to sepsis and empyema. The medical adviser found that the brown pleural fluid drained on 7 November should have prompted diagnosis; the pH measurement the next day was confirmatory. Early diagnosis would have improved survival prospects, though oesophageal perforation carries inherently high mortality. An additional error was calcium infusion via peripheral vein causing arm tissue damage; central venous access should have been used.

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

Specialties

surgeryanaesthesiaintensive carerespiratory medicine

Error types

diagnosticdelay

Clinical conditions

oesophageal perforationboerhaave syndromeempyemasepsispneumothoraxpleural effusionfaecal peritonitisanastomotic dehiscenceatelectasisacute kidney injurytype II diabetes mellitusobesitychronic obstructive pulmonary diseaseemphysemaatherosclerotic coronary vascular disease

Procedures

hernia repaircolonic tumour resectionintercostal catheter insertionexploratory laparoscopysurgical repair of faecal leakperipheral intravenous calcium infusion

Contributing factors

  • spontaneous oesophageal perforation (Boerhaave syndrome)
  • faecal leak from colon anastomosis (colonic perforation/dehiscence)
  • delayed diagnosis of oesophageal perforation (6-day delay)
  • Type II diabetes
  • obesity (BMI 38.1)
  • emphysema
  • atherosclerotic coronary vascular disease
  • peripheral vein calcium infusion causing tissue damage

Coroner's recommendations

  1. Improve recognition and diagnosis of oesophageal perforation in regional hospital settings, particularly the diagnostic significance of brown-coloured pleural fluid with elevated lactate dehydrogenase suggesting gastric content
  2. Ensure calcium infusions are administered via central venous access, not peripheral lines
  3. Maintain heightened clinical suspicion for oesophageal perforation in post-operative patients presenting with new pleural effusion and sepsis
Full text
Official source Archived copy

Related cases

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.

Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —