Inquest into the Death of Margaret Patton Brooks

43y · Female·Haemorrhage Associated with Penetrations of the Aorta

Margaret Brooks, a 43-year-old woman, died from haemorrhage associated with aortic penetrations during laparoscopic gastric band insertion at Kaleeya Hospital on 8 September 1999. The operation was undertaken for weight management (BMI 35). During insertion of a 15mm trocar to create a port for the gastric band, the cutting blade penetrated the coeliac axis and both walls of the aorta in a single continuous motion. The surgeons did not observe the blade's penetration of these deep structures because they were compressed against the abdominal wall, preventing activation of the trocar's safety shield. Despite immediate recognition of bleeding and conversion to open surgery with vascular repair, the deceased died from traumatic blood loss and organ ischaemia. The coroner found this was misadventure, not medical negligence, and noted the difficulty of laparoscopic surgery in the upper abdomen near vital structures. A recommendation was made regarding patient information on trocar mechanics and risks.