Coronial
WAhospital

Inquest into the Death of Gerda Theresia DUNKEL

Deceased

Gerda Theresia DUNKEL

Demographics

44y, female

Coroner

Coroner Linton

Date of death

2015-11-06

Finding date

2019-06-21

Cause of death

pulmonary thromboembolism in a woman with likely myeloproliferative neoplasm

AI-generated summary

A 44-year-old previously healthy woman with BMI 30.5 and minimal comorbidities (snoring, back pain, knee pain) underwent elective sleeve gastrectomy for weight loss. Nine days post-op she presented with splenic rupture requiring emergency surgery. She subsequently developed portal vein thrombosis and was anticoagulated. Five days later she developed bilateral leg DVT and pulmonary embolism despite anticoagulation, and died from catastrophic pulmonary embolism. Post-mortem identified an undiagnosed myeloproliferative neoplasm (Calreticulin exon 9 mutation) predisposing to thrombosis. Expert evidence indicates this rare haematological condition was undetectable pre-operatively. Key clinical lesson: borderline BMI candidates require thorough investigation of claimed comorbidities, documented trial of conservative measures, and consideration of non-surgical medical management (statins, lifestyle modification) before proceeding with elective bariatric surgery.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general surgerybariatric surgeryhaematologyintensive careemergency medicine

Error types

diagnosticcommunicationdelay

Drugs involved

heparinrivoxabarinalteplaseoral contraceptive pill

Clinical conditions

myeloproliferative neoplasmsplenic infarctionsplenic ruptureportal vein thrombosisdeep vein thrombosispulmonary embolismdyslipidaemiafatty liver diseaseelevated ferritin

Procedures

sleeve gastrectomyemergency splenectomylaparotomyIVC filter insertion

Contributing factors

  • undiagnosed myeloproliferative neoplasm (Calreticulin exon 9 mutation)
  • splenic rupture with infarction
  • portal vein thrombosis
  • bilateral deep vein thrombosis
  • inadequate pre-operative investigation of comorbidities
  • lack of documented trial of non-surgical management options
  • surgical stress precipitating thrombosis cascade in predisposed patient

Coroner's recommendations

  1. Commend the practice adopted by Dr Watson of requiring patients at lower end of BMI range to write a letter explaining why surgery is important to them, and to provide documented risk-benefit discussion
  2. Recommend this practice be adopted by other bariatric surgeons for borderline cases
  3. Recommend thorough investigation and documentation of claimed comorbidities in patients with BMI 30-35
  4. Recommend documented evidence of attempted conservative management (dietary modification, exercise programs, medical therapy) before proceeding with bariatric surgery in borderline cases
  5. Recommend consideration of non-surgical medical management options (statins, diabetes prevention programs) for patients with obesity-related risk factors
Full text
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