Finding into death of Maxwell Norman Campbell

68y · Male·pulmonary thromboembolism in the setting of recent surgery

A 68-year-old man died from pulmonary thromboembolism following revisional gastric bypass surgery. He developed multiple post-operative complications including fever, elevated inflammatory markers, and a possible bowel perforation requiring re-operation. A MET call at 5:30am revealed non-specific symptoms consistent with several diagnoses (sepsis, cardiac event, PE). Clinical examination, investigations and differential diagnosis approach were appropriate at that time. A vasovagal episode occurred post-shower at 10am but was reasonably attributed to post-operative recovery. No CTPA was performed prior to cardiac arrest at 12:30pm. The coroner found medical care was appropriate and the death was not preventable, as pulmonary embolism is rare in this surgery type and presented with minimal specific clinical clues. Key learning: the diagnostic challenge of undifferentiated post-operative deterioration; importance of documentation; and family escalation protocols.