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.
Error types
Drugs involved
Clinical conditions
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
- 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
- Educational programs should be directed toward identifying and managing risk factors related to gastric banding that may arise throughout a patient's life
- Education should reach both experienced doctors in private practice and junior hospital doctors
- 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
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