Finding into death of Lauren Katherine James

Contributing factors

• Failure to investigate cause of increasing post-operative pain on third post-operative day
• Inadequate clinical assessment of asymmetrical swelling and severe pain in left thigh
• Failure to order investigations (blood tests, imaging) despite presentation with potential post-operative complications
• Absence of clear communication between treating surgeon, clinic doctor, and patient regarding post-operative management plan
• Use of injectable pethidine in ambulatory setting without adequate observation period
• Discharge of patient without clear escalation protocol or safety net
• Delayed and inadequate clinical response to patient's deterioration in the afternoon of 22 January
• Failure to review patient in timely manner following morning consultation
• Inadequate communication during telephone handover from Mr Sormann to Mr Dieu regarding urgency of case
• Confusion regarding responsibility for post-operative care due to clinic's modified care arrangement

Coroner's recommendations

1. Good lines of communication and clear communication between medical practitioners, staff and patients are imperatives for patient safety in day procedure clinics
2. Clear demarcation of responsibilities between medical practitioners involved in post-operative care is essential
3. Protocols should be established regarding post-operative management arrangements in day procedure clinics to avoid confusion about responsibility
4. Injectable opiates should be administered with adequate observation periods
5. Patients undergoing cosmetic surgery should have direct access to their treating surgeon for post-operative concerns