Coroner's Finding: Baldock, Andrea Eileen

46y · Female·combined effects of aspiration pneumonia due to gastroparesis following sleeve gastrectomy and ischaemic heart disease with cardiomegaly

A 46-year-old woman died from aspiration pneumonia due to gastroparesis following sleeve gastrectomy, complicated by ischaemic heart disease. Post-operative recovery was beset with persistent vomiting, dehydration, and electrolyte disturbances from 10 May onwards. Despite multiple presentations to hospital and general practice over three months, management was described as ad hoc, unstructured, and largely unmonitored without direct supervision. The patient experienced recurrent episodes of ventricular tachycardia and ultimately aspirated food into her lungs. While gastroparesis is a recognised but uncommon complication of sleeve gastrectomy, the coroner identified failure to implement a structured, closely monitored post-operative care plan as a significant deficiency. The case illustrates that weight reduction surgery carries non-trivial risks and should follow exhaustion of non-invasive options.