Inquest into the Death of Julissa Teresa GILBERT

57y · Female·Intra-abdominal Haemorrhage following Appendectomy, with contributing factor of Coronary Arteriosclerosis

A 57-year-old woman with COAD, hypertension, and unrecognized severe coronary atherosclerosis presented with appendicitis. Surgery was performed by an unsupervised surgeon operating on friable tissues with limited visibility. Post-operatively, mesenteric tears caused intra-abdominal haemorrhage (1600mls), but this was misdiagnosed as septic shock. The locum doctor managing post-operative care failed to recognize critical clues: severely low haemoglobin (53 g/L), persistent hypotension despite vasopressors, and lactosis/acidosis. Key failures included: incomplete handover between anaesthetist and post-operative team; misinterpretation of blood gas analysis; failure to involve the surgeon when post-operative deterioration was apparent; and absence of surgeon assistance during the operation. Earlier recognition, surgical consultation, and prompt blood transfusion with theatre return might have been lifesaving, though deterioration was extremely rapid.