Coroner's Finding: John Reginald Beech

64y · Male·Postoperative intra-abdominal bleeding from pancreatic artery injury and its consequences

John Reginald Beech, 64, died at Sydney Adventist Hospital on 24 April 2007 from postoperative intra-abdominal hemorrhage following colonic surgery. One week earlier, he underwent high anterior resection and hernia repair for a malignant polyp. Post-operatively, he developed hemorrhage from a small pancreatic artery that was not recognized initially. The anaesthetist incorrectly diagnosed anaphylaxis and failed to order blood tests, though he sought ICU input. The surgeon waited for results but then prioritized another patient's operation before returning the critically ill patient to theatre, causing delays of over 3 hours. The patient subsequently arrested and suffered hypoxic brain injury, leading to withdrawal of care. The coroner found the surgeon's evidence unreliable and both clinicians erred: earlier blood testing and prompt return to theatre would likely have prevented death. Recommendation made to Health Care Complaints Commission.