Coronial
TAShospital

Coroner's Finding: Briffa, Gennette Anne

Deceased

Gennette Anne Briffa

Demographics

73y, female

Date of death

2022-01-30

Finding date

2024-07-25

Cause of death

sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopic revision of gastric bypass

AI-generated summary

A 73-year-old woman died from sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopic revision of gastric bypass surgery. She had complex medical history with multiple post-operative complications including haematemesis, dehydration, vomiting, and deep vein thrombosis. The critical failure was delayed recognition and management of sepsis in the immediate post-operative period (from 25 January 2022 onwards). Despite MET calls being made, an intensivist was not involved early enough. The coroner found the response to post-surgical complications was below acceptable standard. Early recognition of sepsis signs, prompt intensivist involvement, early potent intravenous antibiotics, renal replacement therapy, and circulatory support may have altered the outcome.

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

Specialties

bariatric surgerygeneral surgeryintensive careemergency medicine

Error types

diagnosticdelay

Drugs involved

apixaban

Clinical conditions

sepsisanastomotic breakdownoesophageal perforationhaematemesisdehydrationacute liver failureacute renal failurehypotensionpulmonary embolismdeep vein thrombosisoedema

Procedures

gastric band removallaparoscopic single anastomosis gastric bypasscolonoscopylaparoscopic reversal of gastric bypassintra-operative gastroscopynaso-enteric tube insertionmanual disimpaction

Contributing factors

  • failure to identify sepsis with certainty in immediate post-operative period
  • delayed involvement of intensivist
  • anastomotic breakdown with perforation
  • delayed recognition of clinical deterioration
  • complex post-operative course with multiple complications
Full text

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