Coronial
WAhome

Inquest into the Death of Levissianos, Katina

Deceased

Katina Levissianos

Demographics

55y, female

Date of death

2009-11-04

Finding date

2013-05-16

Cause of death

Aspiration of Gastric Contents in Association with Gastric Necrosis in a patient with a Gastric Band Device

AI-generated summary

A 55-year-old woman died of aspiration following gastric necrosis associated with a gastric band device inserted in 2008. She presented with vomiting and feeling unwell starting 31 October 2009, but never complained of pain despite having excruciating necrosis. Her GP made home visits on 2 and 3 November, diagnosed a likely viral infection, and prescribed antibiotics and anti-emetics. The deceased refused hospital admission. Her stomach had herniated through the band device, causing obstruction and necrosis within approximately 4-5 days. Death was likely preventable if she had reported excessive vomiting to her surgeon or if her GP had recognized that significant vomiting warrants urgent surgical review. Key clinical lesson: GPs require education about bariatric surgery complications, specifically that excessive vomiting mandates urgent specialist review and possible device loosening/removal, as vomiting itself can cause stomach herniation through the band.

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

Specialties

general surgerybariatric surgerygeneral practicepathology

Error types

communicationdiagnosticdelaysystem

Drugs involved

amoxicillin/clavulanateprochlorperazineparacetamol

Clinical conditions

gastric band herniationgastric necrosisgastric obstructionaspirationsepsisvomitingmorbid obesity

Procedures

laparoscopic adjustable gastric band insertion

Contributing factors

  • stomach herniation through gastric band device
  • failure to recognize vomiting as sign of band complication
  • excessive vomiting preceding herniation
  • lack of communication between GP and bariatric surgeon
  • GP not involved in post-operative follow-up or education
  • patient's reluctance to seek hospital care despite medical advice
  • patient did not report vomiting symptoms to bariatric surgeon
  • GP not administering anti-emetics as trigger for specialist review

Coroner's recommendations

  1. A Specialist General Practice Group should develop and extend training programs to raise awareness about common and life-long concerns and complications associated with gastric banding surgery, including the significance of prolonged vomiting in patients with prior gastric banding
  2. Educational programs should be directed toward identifying and managing risk factors related to gastric banding that may arise throughout a patient's life
  3. Education should reach both experienced doctors in private practice and junior hospital doctors
  4. GPs should understand that repetitive vomiting or strenuous retching in a patient with a gastric band mandates urgent review to allow the band to be loosened or removed if necessary
Full text

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.