Coronial
VIChospital

Finding into death of Thelma Katherine Holt

Deceased

Thelma Katherine Holt

Demographics

79y, female

Coroner

Coroner Dr Jane Hendtlass

Date of death

2009-03-14

Finding date

2013-08-13

Cause of death

pneumonia in the setting of acute peritonitis due to perforated stomach (operated)

AI-generated summary

Mrs Thelma Katherine Holt, a 79-year-old woman with multiple comorbidities including obesity, vascular disease, hypertension, and prior Nissen fundoplication, underwent placement of a second intragastric balloon on 11 September 2008 for weight loss prior to hernia repair. On 30 January 2009, she presented with severe abdominal pain and vomiting. CT imaging confirmed gastric outlet obstruction from the balloon. Despite this, her gastroenterologist advised against urgent removal, citing lack of experience with balloons. She was managed conservatively with nasogastric drainage and fluids. The nasogastric tube was capped on 31 January without verifying patency. By 1 February, her condition deteriorated, and emergency surgery revealed large gastric perforation with peritonitis. She died 14 March 2009 from pneumonia in the setting of acute peritonitis. Key preventable failures included: Dr M. placing a second balloon in a high-risk elderly patient with complex comorbidities; failure to recognize significant gastric obstruction; capping the nasogastric tube without ensuring function; and administering large fluid volumes without monitoring output. Clinical lessons include careful patient selection for balloons, active monitoring for obstruction, and ensuring specialist advice is acted upon.

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Specialties

gastroenterologygeneral surgeryintensive caregeneral practiceemergency medicine

Error types

diagnosticproceduralcommunicationsystemdelay

Drugs involved

sertralinereductilorlistatesomeprazoletazacmorphinemetoclopramidekytrilglyceryl trinitrate

Clinical conditions

obesitygastric outlet obstructiongastric perforationperitonitispneumoniaabdominal incisional herniahiatus herniagastro-oesophageal reflux diseaseischaemic gastric perforationvascular diseasechronic renal impairmentasthmaobstructive sleep apnoea

Procedures

intragastric balloon placementendoscopyemergency laparotomynasogastric tube insertionhernia repairgastrectomybowel resection

Contributing factors

  • intragastric balloon causing gastric outlet obstruction
  • gastric perforation due to stomach distension
  • failure to recognize significance of gastric obstruction
  • capping nasogastric tube without ensuring patency
  • administration of large fluid volumes without monitoring output
  • patient unsuitable for intragastric balloon due to age, comorbidities, and prior surgery
  • inadequate monitoring for complications during balloon placement
  • Dr M.'s conviction that complete mechanical obstruction from balloons does not occur
  • Dr P.'s acceptance of Dr M.'s reassurance without verification
  • failure to comply with consultant's orders regarding nasogastric tube management
  • cascade of recurrent ischemia of gastrointestinal tract

Coroner's recommendations

  1. Royal Australasian College of Physicians and Gastroenterological Society of Australia should facilitate training and mentoring service and recording mechanism for adverse events for members practicing in bariatric gastroenterology using intragastric balloons
  2. Royal Australasian College of Physicians and Gastroenterological Society of Australia should develop clinical update advising gastroenterologists to regularly monitor patients for abdominal hernia while balloon is in place, particularly during periods of rapid weight loss
  3. Royal Australasian College of Physicians and Gastroenterological Society of Australia should develop clinical update advising against placing second intragastric balloon in patients with characteristics and comorbidities similar to Mrs Holt
  4. Epworth Hospital should ensure nursing staff and hospital medical staff follow directions of consultant physicians and communicate reasons if they choose not to follow such directions back to the consultant physician
  5. Royal Australasian College of Physicians and Gastroenterological Society of Australia should develop clinical update advising that patients seeking intragastric balloon should be carefully screened and rejected if they do not meet established guidelines determined by the profession and device manufacturer
Full text
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