Inquest into the Death of Julissa Teresa GILBERT

Contributing factors

• Mesenteric tears during appendectomy due to friable tissue and traction during operation
• Lack of surgical registrar assistance during procedure
• Misdiagnosis of post-operative deterioration as septic shock rather than haemorrhage
• Failure to recognize critical blood gas findings (haemoglobin 53 g/L, low haematocrit)
• Incomplete handover from anaesthetist to post-operative medical team
• Erroneous reporting that appendix was ruptured, when it was only gangrenous
• Use of vasopressors without adequate fluid/blood product resuscitation
• Failure to consult surgeon when post-operative hypotension persisted despite treatment
• Absence of general physician available after hours for consultation
• Pre-existing severe coronary artery disease and COAD compromised cardiac reserve

Coroner's recommendations

1. Implementation of structured post-operative handover protocols between anaesthetist and post-operative team
2. Mandatory involvement of operating surgeon in post-operative complications within specified timeframes
3. Improved availability of after-hours senior medical consultation, particularly general physicians and surgical expertise
4. Surgical registrar support for complex abdominal procedures, particularly in patients with friable tissues or challenging anatomy
5. Implementation of colour-coded observation charts (rainbow chart) to visualize patient deterioration trends and trigger escalation protocols
6. Enhanced blood gas analysis interpretation training and recognition of critical findings such as severe haemodilution
7. Guidelines for earlier blood product availability in post-operative sepsis management
8. Enhanced training on differential diagnosis of post-operative hypotension (haemorrhage vs sepsis vs cardiac)
9. Development of clear escalation pathways when vasopressor requirements increase despite fluid resuscitation