Inquest into the death of Henry George Wilson aka Albert Wilson

77y · Male·sepsis due to retroperitoneal collection after biliary stent insertion on a background of colorectal carcinoma with liver metastases causing biliary obstruction

A 77-year-old Aboriginal man died from sepsis following a percutaneous transhepatic cholangiography (PTC) procedure that perforated his duodenum. Critical failures included: delayed diagnosis and treatment of peritonitis (diagnosis made at 1.20pm on 18 September, appropriate management delayed until late afternoon); lack of communication with family despite prior assurances; failure to involve family in end-of-life decisions; poor coordination between surgical and interventional radiology teams; and failure to report a clearly reportable death to the coroner (injury-related, unexpected death). The patient died in severe pain with inadequate symptom management. The coroner found management delayed after peritonitis diagnosis but noted this delay unlikely changed outcome. Key lessons: early escalation and investigation of post-procedure complications, urgent sepsis management, family involvement in decisions for elderly patients, inter-professional communication, and proper reporting obligations.