Finding into death of Maxwell Norman Campbell
Deceased
Maxwell Norman Campbell
Demographics
68y, male
Date of death
2014-11-16
Finding date
2018-10-18
Cause of death
pulmonary thromboembolism in the setting of recent surgery
AI-generated summary
A 68-year-old man died from pulmonary thromboembolism following revisional gastric bypass surgery. He developed multiple post-operative complications including fever, elevated inflammatory markers, and a possible bowel perforation requiring re-operation. A MET call at 5:30am revealed non-specific symptoms consistent with several diagnoses (sepsis, cardiac event, PE). Clinical examination, investigations and differential diagnosis approach were appropriate at that time. A vasovagal episode occurred post-shower at 10am but was reasonably attributed to post-operative recovery. No CTPA was performed prior to cardiac arrest at 12:30pm. The coroner found medical care was appropriate and the death was not preventable, as pulmonary embolism is rare in this surgery type and presented with minimal specific clinical clues. Key learning: the diagnostic challenge of undifferentiated post-operative deterioration; importance of documentation; and family escalation protocols.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- recent major abdominal surgery with extensive adhesions
- obesity
- immobility post-operatively
- ischaemic heart disease
- post-operative inflammatory response
- undiagnosed pulmonary embolism
Coroner's recommendations
- The Warringal Private Hospital introduced the 'Ramsey Rule' (approximately 2017) empowering patients and family members to escalate concerns to nursing or medical staff, with brochures provided to families in each room. Coroner stated this addressed the key prevention opportunity identified and no further recommendations are necessary.
Full text
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