Inquest into the death of Paul MORTIMER

65y · Male·ischaemic heart disease following complications of colorectal surgery

A 65-year-old man with significant comorbidities (cardiomyopathy, diabetes, obesity) underwent colorectal surgery for adenocarcinoma. Post-operative course was complicated by anastomotic breakdown causing sepsis on day 12 post-discharge, requiring readmission. A retained surgical sponge was discovered during emergency reoperation but experts unanimously agreed it did not cause the anastomotic breakdown and minimally, if at all, impaired infection control. Death resulted from ischaemic heart disease under strain from severe sepsis. Discharge planning was appropriate, home care adequate, and surgical technique competent. The sponge retention represented a preventable counting error with no bearing on fatal outcome. Key lessons: robust surgical count procedures with escalation protocols for discrepancies are essential; retained foreign bodies are preventable events requiring systematic safeguards.