Inquest into the Death of Lee MILCHERDY

75y · Female·Complications including acute pancreatitis and refractory intra-abdominal sepsis with malnutrition, deconditioning and bronchopneumonia following an endoscopic retrograde cholangiopancreatography (ERCP) for a clinically suspected diagnosis of choledocholithiasis in an elderly lady with chronic obstructive pulmonary disease

Lee Milcherdy, 75, died from complications including acute pancreatitis and refractory intra-abdominal sepsis following an unnecessary ERCP procedure. An MRCP scan on 12 October 2018 showed no gallstone, making the planned ERCP inappropriate. However, this critical result was not communicated from Joondalup Health Campus to Sir Charles Gairdner Hospital, where the ERCP was performed on 15 October 2018. The procedure caused serious complications including perforation, sepsis, and multi-organ dysfunction. Key clinical lessons: ensure all relevant investigation results are explicitly communicated before procedures, particularly between hospitals; maintain effective handover procedures with documented confirmation of all pending/completed investigations; verify imaging availability at receiving facilities before proceeding with procedures; and maintain high vigilance for communication gaps in inter-hospital transfers.