Finding into death of Robert Gerard Dimattina
Deceased
Robert Gerard Dimattina
Demographics
58y, male
Date of death
2019-08-20
Finding date
2021-01-29
Cause of death
Aspiration pneumonia complicating small bowel obstruction in the setting of recent elective subtotal colectomy for the treatment of colorectal adenocarcinoma
AI-generated summary
A 58-year-old man died from aspiration pneumonia complicating small bowel obstruction six days after elective laparoscopic subtotal colectomy for colorectal cancer. On post-operative day 6, he developed fever, tachycardia, and hypoxia. A surgeon attempted nasogastric tube (NGT) insertion to relieve abdominal distension, but the patient vomited during the procedure and lost consciousness. He could not be resuscitated. The coroner's review found the surgical care was appropriate, the operation was uneventful, and daily post-operative reviews showed progressive improvement until the acute deterioration. NGT insertion carries inherent risks of aspiration, particularly when vomiting occurs. The coroner identified no preventable opportunities, though recommended RACS use this case educationally to highlight the uncommon but severe risks of NGT insertion.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- vomiting during nasogastric tube insertion
- aspiration of gastric contents
- small bowel obstruction with kinking of bowel through omental defect
- post-operative ileus
Coroner's recommendations
- That the Royal Australasian College of Surgeons (RACS) use a de-identified version of this case as an educative tool to remind its members of the uncommon and unexpected severe risks associated with NGT insertion
Full text
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