Finding into death of Noella Rae Clohesy
Deceased
Noella Rae Clohesy
Demographics
62y, female
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.
Specialties
Error types
Clinical conditions
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
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