Coroner's Finding: PRATT Shirley May

66y · Female·acute necrotising haemorrhagic mediastinitis

Mrs Pratt, aged 66, underwent elective gastroscopy at Kapunda Hospital. During the procedure she heaved, and blood was noted at the gastro-oesophageal junction. She was discharged the same afternoon with pain, only to return within hours with pleuritic chest pain and shortness of breath. A perforation of the oesophagus likely occurred during the procedure. The diagnosis of perforated oesophagus was considered but Mrs Pratt was kept at the small rural hospital overnight rather than transferred urgently to the Royal Adelaide Hospital. Transfer occurred next morning but by then mediastinitis had developed with high contamination. Despite surgery, she died from necrotising haemorrhagic mediastinitis with pericardial involvement. The surgeon Mr Gue bore primary responsibility for ensuring appropriate escalation of care. Earlier transfer would have approximately doubled her chances of survival. Key lessons: specialists performing invasive procedures in rural settings must have formal transfer agreements with teaching hospitals, clear emergency protocols, and must take active responsibility for post-operative escalation decisions—not delegate this to inexperienced generalists.