Inquest into the Death of Levissianos, Katina

55y · Female·Aspiration of Gastric Contents in Association with Gastric Necrosis in a patient with a Gastric Band Device

A 55-year-old woman died of aspiration following gastric necrosis associated with a gastric band device inserted in 2008. She presented with vomiting and feeling unwell starting 31 October 2009, but never complained of pain despite having excruciating necrosis. Her GP made home visits on 2 and 3 November, diagnosed a likely viral infection, and prescribed antibiotics and anti-emetics. The deceased refused hospital admission. Her stomach had herniated through the band device, causing obstruction and necrosis within approximately 4-5 days. Death was likely preventable if she had reported excessive vomiting to her surgeon or if her GP had recognized that significant vomiting warrants urgent surgical review. Key clinical lesson: GPs require education about bariatric surgery complications, specifically that excessive vomiting mandates urgent specialist review and possible device loosening/removal, as vomiting itself can cause stomach herniation through the band.