Finding into death of Cherie Virginia Pearl Guest

Contributing factors

• Patient not medically fit for surgery due to severe restrictive lung disease, obesity, kyphoscoliosis, cardiac failure, and diabetes
• Failure to perform proper pre-operative multi-disciplinary assessment and optimisation
• Surgery performed at inappropriate facility (private day surgery centre without critical care services) for ASA-4 patient
• Surgeon failed to undertake own fitness assessment and ignored concerns from anaesthetist
• Anaesthetist failed to clearly decline services and communicate risks to patient
• Hospital CEO failed to enforce patient selection criteria policy excluding ASA-4 patients
• Inadequate monitoring during procedure (no pulse oximeter provided by hospital)
• Inadequate communication about decompensation during first stage of procedure
• Failure to obtain informed consent regarding identified risks and option to stop second stage
• Administration of medication (Xylocaine) against patient's expressed allergy concerns
• Choice of femtosecond laser for first stage inappropriate for this patient

Coroner's recommendations

1. The Royal Australian and New Zealand College of Ophthalmologists should review and strengthen guidance requiring ophthalmologists to undertake their own assessment of patient fitness for surgery, particularly regarding ability to lie flat and tolerance of general anaesthesia, and to properly consult with anaesthetists when concerns are raised.
2. Ophthalmologists should not rely on employee-conducted 'trial runs' without proper medical supervision as adequate assessment tools for surgical fitness.
3. Day surgery centres should rigorously enforce patient selection criteria policies and not admit patients outside accepted parameters regardless of pressure from surgeons.
4. Anaesthetists in elective procedures should clearly communicate fitness concerns to both surgeon and patient, and should not make themselves available as 'back up' when they have determined a patient is not fit for the procedure; instead they should withdraw services.
5. All surgical teams should ensure clear communication and monitoring during procedures, particularly regarding patient deterioration, and establish unambiguous roles and responsibilities for all participants.
6. Informed consent processes must include discussion of material risks identified by any member of the treating team, options to proceed or decline, and potential consequences of deterioration.
7. Hospitals should ensure appropriate monitoring equipment is available and used during procedures for at-risk patients.
8. Root cause analyses and sentinel event reviews should be transparent, factually accurate, and include family involvement to improve understanding of adverse events and prevent recurrence.