Finding into death of Robert Gerard Dimattina

58y · Male·Aspiration pneumonia complicating small bowel obstruction in the setting of recent elective subtotal colectomy for the treatment of colorectal adenocarcinoma

A 58-year-old man died from aspiration pneumonia complicating small bowel obstruction six days after elective laparoscopic subtotal colectomy for colorectal cancer. On post-operative day 6, he developed fever, tachycardia, and hypoxia. A surgeon attempted nasogastric tube (NGT) insertion to relieve abdominal distension, but the patient vomited during the procedure and lost consciousness. He could not be resuscitated. The coroner's review found the surgical care was appropriate, the operation was uneventful, and daily post-operative reviews showed progressive improvement until the acute deterioration. NGT insertion carries inherent risks of aspiration, particularly when vomiting occurs. The coroner identified no preventable opportunities, though recommended RACS use this case educationally to highlight the uncommon but severe risks of NGT insertion.