Coroner's Finding: Russell; Patricia Joy

74y · Female·empyema/sepsis complicating oesophageal perforation following a complicated elective hernia repair

Mrs Russell, a 74-year-old woman with diabetes, obesity, COPD and coronary disease, underwent elective hernia repair in November 2016 at a regional hospital. An unexpected colon tumour was removed during surgery. She subsequently developed a faecal leak from the colon anastomosis requiring surgical repair. Critically, she also suffered a spontaneous oesophageal perforation (Boerhaave syndrome) likely on 6-7 November, but this diagnosis was not made until 13 November—a six-day delay. The perforated oesophagus led to sepsis and empyema. The medical adviser found that the brown pleural fluid drained on 7 November should have prompted diagnosis; the pH measurement the next day was confirmatory. Early diagnosis would have improved survival prospects, though oesophageal perforation carries inherently high mortality. An additional error was calcium infusion via peripheral vein causing arm tissue damage; central venous access should have been used.