Inquest into the Death of June Valerie LOBBAN

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

1. 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
2. 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