VIChospital

Finding into death of Noella Rae Clohesy

Deceased

Noella Rae Clohesy

Demographics

62y, female

Coroner

State Coroner Judge Ian L Gray

Date of death

2006-11-17

Finding date

2014-08-29

Cause of death

Multi-organ failure due to lacerated abdominal aorta complicating laparoscopic band and hernia repair surgery

AI-generated summary

A 62-year-old woman died from multi-organ failure caused by a lacerated abdominal aorta sustained during elective laparoscopic gastric band surgery in 2006. The aorta was cut by a Visiport trocar blade at the start of the procedure. Although the surgeon conducted a careful survey for bleeding and found none, blood was lost into the retroperitoneum, which remained undetected for over four hours. The anaesthetist noted persistent hypotension from early in the operation but failed to communicate concerns to the surgeon until very late. Key lessons: retroperitoneal bleeding can occur without visible intra-abdominal signs; surgeons and anaesthetists must communicate about haemodynamic concerns during surgery; and there is a need for greater awareness of aortic perforation risks during Visiport insertion, particularly in obese patients.

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

Specialties

general surgeryanaesthesiaintensive care

Error types

proceduralcommunicationdelay

Clinical conditions

hypovolaemic shockmulti-organ failureretroperitoneal haemorrhageischaemic heart diseasehypertensionobesity

Procedures

laparoscopic gastric band insertionhernia repairVisiport trocar insertionlaparoscopy

Contributing factors

Lacerated aorta from Visiport trocar blade insertion
Retroperitoneal blood loss without intra-abdominal signs
Failure of anaesthetist to communicate hypotension concerns to surgeon
Delayed recognition of occult bleeding
Surgeon's departure from hospital during critical period
Ischaemic heart disease, hypertension, smoking history, obesity

Coroner's recommendations

The Royal Australasian College of Surgeons should state or re-state and build into education programs dissemination of the fact that significant retroperitoneal bleeding can occur without any intra-abdominal signs
The Royal Australasian College of Surgeons should produce guidelines for obesity training based on advanced laparoscopic experience and ensure familiarity with cross clamping major vessels is taught during training
Dissemination of lessons learned from this case should be made known to the wider surgical and anaesthetic communities including other subspecialties involved in advanced laparoscopic procedures
Respective professional colleges in Victoria for anaesthesia and surgery should incorporate mandatory training for those in the private sector dealing with elective procedures to undergo specific training in dealing with emergency situations on an annual basis

Full text

Official source Archived copy

Related cases from VIC

VIChome2017-12-04

Finding into death of Leigh Thomas Aiple

31y · Male·Pulmonary thromboembolism

A 31-year-old man with obesity (BMI 40.2) and sleep apnoea underwent extensive cosmetic surgery in Malaysia (liposuction, abdominoplasty, chest lipectomy, and subsequent facial procedures) across two operations within fi…

plastic and reconstructive surgerygeneral surgerydiagnosticmedicationenoxaparin

VIChospital2016-04-14

Finding into death of Kelly Maree Richards

29y · Female·Exsanguination post tubal ligation procedure

A 29-year-old woman died from exsanguination following an iatrogenic injury during elective laparoscopic tubal ligation at a regional hospital. A vascular injury to the right external iliac artery occurred during the pro…

general surgerygynaecologyproceduralcommunicationpacked red blood cells

VIChospital2015-02-12

Finding into death of Mary Mulqueen

57y · Female·small bowel ischaemia; distal gastrectomy

57-year-old woman underwent distal gastrectomy and vagotomy for gastric outlet obstruction in August 2008. Coroner found she suffered an aberrant surgical reconstruction during the procedure, with abnormal bowel anatomy …

general surgerygastroenterologyproceduraldiagnosticesomeprazole

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.