Finding into death of Lilian Olive Blanche McClurkin

Contributing factors

• anastomotic leak at gastric sleeve staple line
• contained peritoneal leak that burst on day 3 post-operatively
• difficulty detecting abdominal distension in obese patient
• inadequate communication between nursing and medical staff regarding patient deterioration
• elevated creatinine and urea on day 3 not reported to surgeon
• absence of drain to detect potential leak
• late timing of procedure (1755 hours, 3.5 hours duration) in an extremely delicate operation
• extensive unexpected adhesions from previous surgeries complicating the procedure

Coroner's recommendations

1. Introduction of Medical Emergency Team (MET) call criteria to establish thresholds for reporting patient condition changes to consultant or registrar
2. Registrar to document in history when patient has been reviewed
3. Melbourne Pathology to contact consultant and nurse in charge regarding abnormal blood results in a timely manner
4. All laparoscopic revision bariatric cases to be managed in High Dependency Unit
5. Staff to document in history when they have contacted consultants regarding change of condition
6. Grade 5 nurse on duty to be notified of any change in patient's condition
7. Nursing staff to document in patient's history when reviewed by consultant
8. Nursing staff to document in history if telephone contact made regarding patient's condition between medical and nursing staff