Coroner's Finding: Carroll, Terence John

Contributing factors

• oesophageal adenocarcinoma
• emphysema
• chronic alcoholism
• failure to communicate CT scan findings to surgeon
• failure to definitively exclude malignancy before dilation
• delay in diagnosis of oesophageal perforation at referring hospital
• same-day discharge despite post-operative instability and patient frailty
• absence of post-operative vital sign monitoring before discharge
• improper positioning of guidewire during dilation
• patient cachexia and poor physical state

Coroner's recommendations

1. Careful selection of patients for oesophageal dilation procedure with frailty assessment using approved tools such as the Carlson Fragility Index
2. Ensure all relevant pathology and diagnostic imaging results are available at pre-admission clinic and to treating clinicians before procedure
3. Refer to multidisciplinary team for case assessment and planning when malignancy is suspected or confirmed
4. Adequate characterisation of stricture characteristics including location, underlying pathology, and length/complexity before dilation
5. Initial procedure should include biopsy and histological confirmation where high suspicion for malignancy exists
6. Purchase ultraslim flexible gastroscopes and provide formal training to staff
7. Ensure guidewire tip is appropriately located and remains in correct location during procedure via direct sight or fluoroscopy
8. Defer procedure or refer to another facility if necessary equipment is not available
9. Admit frail patients overnight if vital signs are unstable before discharge or if pain increases post-operatively
10. Consult with state-wide endoscopy network to develop appropriate procedures and guidelines
11. Close post-operative monitoring of frail patients before discharge
12. Patients presenting to referring hospital within 24-48 hours post-surgery should be assessed by treating surgical team and transferred to appropriate facility