Inquest into the death of Patrick THOMAS

52y · Male·Intestinal failure/sepsis arising from venous ischemia as a result of superior mesenteric vein division which occurred accidentally during surgical procedure

Patrick Thomas, a 52-year-old man, died from intestinal failure and sepsis following an accidental division of the superior mesenteric vein (SMV) during laparoscopic surgery for colon cancer at Kareena Private Hospital on 9 October 2013. Despite emergency repair with an inferior mesenteric vein graft and transfer to Sutherland Hospital ICU, the graft occluded and his small bowel became non-viable. Critical failures included: (1) the surgeon's erroneous advice that the death need not be reported to the Coroner, resulting in incorrect death certification without coronial notification; (2) absence of Root Cause Analysis at either hospital despite this being a reportable incident; (3) lack of inter-hospital communication protocols when patients transferred between private and public facilities. The coroner found no surgical error in technique but identified systemic failures in hospital governance, review processes, and communication that prevented proper investigation of the adverse outcome.