Inquest into the Death of June Valerie LOBBAN
Deceased
June Valerie LOBBAN
Demographics
69y, female
Date of death
2014-05-09
Cause of death
Intra-abdominal sepsis and shock with multi-organ failure following intestinal perforation (perforated caecum due to ischaemia) complicating a recent lumbar spine laminectomy
AI-generated summary
A 69-year-old woman died from intra-abdominal sepsis and multi-organ failure following a perforated caecum that occurred after lumbar spine surgery. Post-operatively, she developed abdominal distension and pain initially attributed to constipation. A locum RMO appropriately ordered abdominal X-rays showing free air (suggesting perforation), but critical delays occurred: the X-ray was not performed until 24 hours later, results were not communicated urgently to clinicians, and no medical review occurred the following morning despite the RMO's documented plan. By the time a rehabilitation physician reviewed her at 6pm, peritonitis was established. She was transferred to Fremantle Hospital for emergency surgery, but the 12-24 hour delay in diagnosis meant extensive faecal contamination and sepsis had developed. Early imaging on day 3-4 post-op, prompt reporting of radiological findings, and morning medical review would have significantly improved survival prospects.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Delay in diagnosis of bowel perforation
- Failure to perform imaging on day 3-4 post-op despite escalating abdominal symptoms
- Lack of overnight medical cover at SJOG Murdoch
- Inadequate orientation of locum RMO to hospital protocols
- Failure to escalate clinical concerns appropriately through consultant-to-consultant communication
- Lack of morning medical review on 5 May despite documented plan
- Delayed communication of critical radiological findings (free air) to treating team
- Non-urgent ordering of imaging despite clinical indicators
- Interpretation of deteriorating symptoms as constipation rather than alternative diagnosis
- Extended recovery period post-first operation without appropriate ICU admission
- Underlying comorbidities including systemic lupus erythematosus and osteopenia
Coroner's recommendations
- SJOG Murdoch ensure SKG Radiologists contact the appropriate consultant under whom a patient is admitted where there is a serious radiological result requiring urgent attention
- Where overnight care of a patient has required intensive intervention, the clinical nurse manager should ensure that patient receives appropriate medical review the following morning if observations have not warranted earlier review
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