Maxfield, Annette

62y · Female·Haemorrhage caused by abdominoperineal excision of the rectum

A 62-year-old woman died of uncontrollable haemorrhage following an abdominoperineal excision of the rectum (APER) at a remote hospital. The coroner found the operation itself was inappropriate: performed for undiagnosed chronic pain in a patient with extensive surgical history, rather than for malignancy. The surgery should not have been attempted at Mt Isa Hospital by an insufficiently experienced surgeon without specialist anaesthetic support. The patient had not undergone adequate psychological assessment or pain management consultation. During surgery, the surgeon used an unconventional perineal-first approach that multiple experts considered dangerous and unnecessary. When massive haemorrhage occurred, management was delayed by inadequate preoperative blood work, blood product availability, and failure of the anaesthetist to order critical tests promptly. The coroner concluded the death was preventable had appropriate patient selection, surgical approach, facility choice, and emergency response been implemented.