Coronial
TAShospital

Coroner's Finding: Flynn, Christine Joy

Deceased

Christine Joy Flynn

Demographics

68y, female

Date of death

2023-12-05

Finding date

2024-11-07

Cause of death

haemopericardium resulting from perforation of the pericardial sac during laparoscopic hiatus hernia repair

AI-generated summary

Mrs Christine Flynn, aged 68, died from haemopericardium and pericardial tamponade following laparoscopic hiatus hernia repair. A 2mm perforation of the pericardial sac occurred during surgery, likely from mesh tacks placed near the diaphragm. She developed hypotension two hours post-operatively, followed by nausea, collapse, and cardiac arrest. The coroner accepted expert opinion that mesh fixation with tacks in hiatus hernia repair carries catastrophic risks including pericardial injury, with no clear advantage over non-mesh repair. Clinicians should be alert to this risk and consider alternative fixation methods such as glue or avoid mesh entirely in hiatal hernia repairs.

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

Specialties

general surgerycardiothoracic surgeryanaesthesia

Error types

procedural

Clinical conditions

hiatus herniahaemopericardiumpericardial tamponadeacute congestive heart failurecardiac arrest

Procedures

laparoscopic hiatus hernia repairmesh fixation with tacks

Contributing factors

  • use of mesh tacks for fixation in hiatus hernia repair
  • pericardial sac perforation during laparoscopic procedure
  • lack of immediate recognition and intervention for post-operative deterioration

Coroner's recommendations

  1. Practitioners should be alert to the risks of use of tacks for mesh fixation in hiatal hernia repairs
  2. Consider using glue for mesh fixation as an alternative to tacks
  3. Consider avoiding mesh fixation entirely in hiatal hernia repairs
Full text

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