Finding into death of Leanne Fiona MacKenzie

48y · Female·abdominal sepsis in a woman with coronary artery disease, post-repair small bowel perforation in the context of repair of incarcerated incisional hernia

Leanne Mackenzie, 48 years old with Prader-Willi syndrome and intellectual disability, underwent laparotomy for incarcerated incisional hernia on 3 April 2011 at Latrobe Regional Hospital with initial repair but poor postoperative progress. She developed peritonitis and was transferred to Northern Hospital on 4 April. She died of abdominal sepsis caused by small bowel perforation following hernia repair, complicated by underlying coronary artery disease. The coroner found medical care was reasonable and appropriate. Clinical learning: complications of hernia repair including visceral injury require rapid recognition and intervention; patients with Prader-Willi syndrome may present atypical postoperative courses requiring heightened vigilance.