Coronial
VIChospital

Finding into death of Mary Mulqueen

Deceased

Mary Mulqueen

Demographics

57y, female

Date of death

2009-08-09

Finding date

2015-02-12

Cause of death

small bowel ischaemia; distal gastrectomy

AI-generated summary

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 featuring a shortened functional segment and antiperistaltic limb. This reconstruction likely contributed to severe malnutrition and malabsorption over the following year despite multiple attempts at nutritional support. However, the immediate cause of death was acute small bowel ischaemia with sepsis in August 2009, and the specific trigger for this acute deterioration could not be determined. While the surgical reconstruction was aberrant, the coroner could not definitively establish that correcting it earlier would have prevented death.

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

Specialties

general surgerygastroenterologydieteticsintensive careradiology

Error types

proceduraldiagnostic

Drugs involved

esomeprazolecodeineloperamidenoradrenaline

Clinical conditions

gastric outlet obstructionduodenal ulcer with scarringgastroparesissmall bowel ischaemiasepsismalnutritionmalabsorptionhypokalemiahypomagnesiaacute respiratory infection

Procedures

distal gastrectomyvagotomyroux-en-y reconstructiongastroscopycolonoscopynasojejunal tube insertionpercutaneous endoscopic gastrostomygastrografin studieslaparotomy

Contributing factors

  • aberrant surgical reconstruction with shortened functional bowel segment and antiperistaltic limb
  • severe malnutrition and malabsorption
  • profound immune compromise from severe weight loss
  • sepsis
  • failure to identify the aberrant reconstruction during postoperative follow-up

Coroner's recommendations

  1. That the Royal Australasian College of Surgeons consider implementing a process of documenting, by way of photographs or video, and/or independent secondary corroboration (by a relevantly qualified professional) of any alleged observations of evidence of aberrant surgical reconstructions
  2. That the Victorian Surgical Consultative Council educate Surgical Registrars and Surgeons on the importance of checking anatomical landmarks throughout and during the final stage of a Roux-en-Y procedure
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