Coronial
WAhospital

Inquest into the Death of Lee MILCHERDY

Deceased

Lee MILCHERDY

Demographics

75y, female

Coroner

Coroner Jenkin

Date of death

2019-02-28

Finding date

2022-06-23

Cause of death

Complications including acute pancreatitis and refractory intra-abdominal sepsis with malnutrition, deconditioning and bronchopneumonia following an endoscopic retrograde cholangiopancreatography (ERCP) for a clinically suspected diagnosis of choledocholithiasis in an elderly lady with chronic obstructive pulmonary disease

AI-generated summary

Lee Milcherdy, 75, died from complications including acute pancreatitis and refractory intra-abdominal sepsis following an unnecessary ERCP procedure. An MRCP scan on 12 October 2018 showed no gallstone, making the planned ERCP inappropriate. However, this critical result was not communicated from Joondalup Health Campus to Sir Charles Gairdner Hospital, where the ERCP was performed on 15 October 2018. The procedure caused serious complications including perforation, sepsis, and multi-organ dysfunction. Key clinical lessons: ensure all relevant investigation results are explicitly communicated before procedures, particularly between hospitals; maintain effective handover procedures with documented confirmation of all pending/completed investigations; verify imaging availability at receiving facilities before proceeding with procedures; and maintain high vigilance for communication gaps in inter-hospital transfers.

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

Specialties

gastroenterologygeneral surgeryintensive careemergency medicinegeneral medicine

Error types

communicationdiagnosticsystem

Clinical conditions

choledocholithiasis (suspected)acute pancreatitispost-ERCP pancreatitisretroperitoneal perforationrefractory intra-abdominal sepsisduodenal perforationsmall bowel obstructionacute kidney injurypleural effusionascitessystemic inflammatory response syndromeretroperitoneal abscessenterococcus faecium infectioncandida infectionurinary tract infectionexacerbation of COPDiron deficient anaemiahydronephrosismalnutritiondeconditioningbronchopneumoniaelectrolyte abnormalities

Procedures

ERCPMRCPCT scanabdominal ultrasoundlaparotomypercutaneous drainagecholecystostomy drainagenasogastric tube insertion

Contributing factors

  • Failure to communicate MRCP results from Joondalup Health Campus to Sir Charles Gairdner Hospital
  • MRCP result not placed on SCGH electronic system (PACS) before ERCP
  • No medical or nursing handover between JHC and SCGH on day of transfer
  • Transfer to SCGH occurred before morning medical round, preventing review by Dr Richards
  • MRCP result not mentioned in transfer documentation
  • RMO at JHC did not discuss MRCP result with senior clinicians
  • ERCP performed despite negative MRCP showing no gallstone
  • ERCP caused post-procedure pancreatitis and retroperitoneal perforation
  • Delayed recognition and management of retroperitoneal collection

Coroner's recommendations

  1. Maintain increased vigilance by clinical staff at both JHC and SCGH regarding communication of investigation results
  2. SCGH clinicians should check the Perth Radiological Centre (PRC) system for every ERCP patient to ensure awareness of all relevant imaging including any MRCP before the ERCP proceeds, as a failsafe measure
  3. JHC should conduct an audit of its new transfer form to determine whether it is achieving its stated purpose of conveying all relevant clinical information
  4. Continue emphasis on the importance of 'Communicating for Safety' among all clinical staff
Full text
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