Inquest into the Death of Anne RZEPCZYNSKI

Contributing factors

• surgical postponement of 20 days after stent insertion, increasing risk of bile duct inflammation and infection
• post-operative arterial bleeding requiring emergency re-operation on day 1 post-surgery
• bile leak from hepaticojejunal anastomoses following re-operation
• intra-abdominal collections with polymicrobial sepsis
• conservative management without early CT scan or antibiotics despite ultrasound evidence of collections on 3 January
• delayed drainage of infected collections (first drain inserted 20 January)
• absence of specialist liver surgeon during post-operative management period
• Dr R. on annual leave for first two weeks post-operatively
• inadequate nutrition for approximately 10 days
• large bilateral pleural effusions and respiratory failure
• bowel ischaemia and perforation requiring colectomy
• multi-resistant organisms developing later in admission

Coroner's recommendations

1. Royal Australasian College of Surgeons and Australian and New Zealand Hepatic, Pancreatic and Biliary Association should provide guidelines on timing of surgery following bile duct stent insertion if they have not done so already
2. If the Royal Australasian College of Surgeons determines similar surgeries should occur within very limited time, Health Department and National Health Ministers' Advisory Council should reflect this in elective surgery urgency categorisation policies
3. Continued employment of additional liver surgeons at Royal Perth Hospital to ensure specialist post-operative oversight availability