VIChome

Finding into death of Andrew Gilmore

Deceased

Andrew Gilmore

Demographics

17y, male

Coroner

Coroner Kim M. W. Parkinson

Date of death

2009-05-22

Finding date

2013-11-27

Cause of death

intra-abdominal haemorrhage complicating partial pancreatectomy for traumatic pancreatic rupture

AI-generated summary

Andrew Gilmore, a 17-year-old fit and well boy, suffered traumatic pancreatic rupture from a football injury on 9 May 2009. Distal pancreatectomy was performed at Alfred Hospital on 11 May. He was discharged to Hospital in the Home (HITH) program on 19 May despite persistent low-grade pancreatic fistula. On 21 May he developed severe pain and vomiting, managed by phone advice attributing symptoms to medication taken on empty stomach. Pain recurred on 22 May morning with reports of being cold and clammy (suggesting shock), but clinical assessment by on-call registrar unfamiliar with the case resulted in recommendation to wait at home. Critical failure was lack of escalation to consulting surgeon despite recurrent post-operative pain in a complex case. Andrew collapsed and died from intra-abdominal haemorrhage (1400ml) from likely splenic artery breakdown due to pancreatic juice erosion—a rare complication at day 10 post-op. Key lessons: HITH lacks vital sign monitoring; recurrent post-op pain warrants immediate consultant review not phone triage; family communication about escalation pathways was inadequate; information from parents was not conveyed to treating team.

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Specialties

general surgeryemergency medicine

Error types

communicationdelaysystem

Drugs involved

oxycodonetramadolparacetamolibuprofenoctreotidemorphineketamine

Clinical conditions

traumatic pancreatic rupturepancreatic transectionpancreatic fistulapost-operative secondary haemorrhagesplenic artery ruptureintra-abdominal haemorrhagepancreatic surgery complication

Procedures

distal pancreatectomylaparoscopic surgerydrain tube insertion

Contributing factors

failure to escalate to consulting surgeon when patient had recurrent severe pain on 21-22 May
on-call registrar was not familiar with the patient and lacked knowledge of pancreatic surgery complications
absence of regular vital observations in home setting that may have identified deteriorating condition
lack of clarity regarding communication pathways between family and HITH program
information provided by mother at 5.50 a.m. on 22 May regarding patient being cold, clammy and in severe pain was not recorded or conveyed to treatment team
limited telephone assessment without access to vital signs or graphic observation charts
discharge to HITH program with persistent low-grade pancreatic fistula
delegation of clinical decision-making to parents regarding urgency of hospital return

Coroner's recommendations

Alfred Hospital and Alfred HITH Program should review the operation of the program to ensure clarity amongst all clinical and administrative staff regarding proper contact and communication processes when family and carers of HITH patients make contact, and regarding the process for conveying patient information to HITH and the treating team
HITH escalation procedure should be amended to provide that any new, recurrent or escalating pain requires immediate escalation to the treating team consultant for review or alternatively immediate arrangements for re-admission to hospital
HITH escalation procedure should be amended to provide that where concerns as to deterioration are being expressed by the patient or family members, immediate escalation to the treating team consultant for review or alternatively immediate arrangements for re-admission to hospital is required

Full text

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