Finding into death of Christine Ann Stephen

67y · Female·Intra-abdominal sepsis complicating an anastomotic leak following elective surgery to repair a vesico-colic fistula

A 67-year-old woman died from intra-abdominal sepsis following an anastomotic leak from elective colorectal surgery to repair a vesico-colic fistula. The initial surgery on 1 November 2017 was appropriately performed, and the anastomotic leak was detected and managed surgically on 6 November with transfer to ICU. Critical opportunities were missed in the post-ICU care: nursing staff failed to escalate deteriorating signs (increasing lactate and vasopressor requirements) to consultant intensivists on multiple occasions; consultant surgeon and intensivist did not attend the patient in person despite concerning clinical trajectory; and early diagnosis of sepsis was not made. While experts disagreed on whether earlier interventions would have changed outcome, the coroner identified substantial opportunities missed in optimising post-operative care. The case highlights failures in escalation protocols, documentation of clinical discussions, and the importance of consultant-level assessment in severe sepsis.