George, Lynda Margaret - Non-inquest findings

60y · Female·Peritonitis due to anastomotic leak following subtotal colectomy for treatment of synchronous adenocarcinoma of colon

60-year-old woman died from septic shock due to anastomotic leak following subtotal colectomy for synchronous bowel cancers. Early postoperative bronchospasm complicated clinical assessment, leading focus on respiratory rather than abdominal pathology. Leak presented atypically early (day 3 postop) with subtle signs that were missed or misattributed to other causes. Multiple clinicians failed to recognize deterioration or escalate appropriately; ICU involvement was delayed and poorly communicated. Expert review criticized surgical technique (side-to-side vs end-to-end anastomosis), lack of intraoperative air test documentation, and inadequate postoperative monitoring in ICU/HDU setting. However, coroner accepted that presentation was confusing and no single clinician error was pivotal. Systemic failures in recognizing deteriorating patients and escalation were addressed post-incident with implementation of deterioration detection systems and MET team.