Inquest into the death of Souzana Afianos

41y · Female·secondary haemorrhage following gastric banding surgery

A 41-year-old enrolled nurse died from secondary haemorrhage eight days after laparoscopic gastric banding surgery in Darwin. She attended ED on 18 February with post-operative pain; Dr McNair discharged her after two hours without contacting her surgeon. She consulted another doctor on 20 February with wound infection but cancelled her surgical appointment. She died 21 February from massive intra-abdominal bleeding from infected necrotic tissue at the band site. The coroner found the surgery was competently performed with no technical fault. The necrosis and subsequent bleeding were not detectable earlier and resulted from normal surgical risks. Key clinical lesson: establish clear protocols requiring routine notification of operating surgeons when post-operative patients attend ED, even when initial assessment seems reassuring. The coroner noted the discharge protocol was ambiguous and inadequate.