Coroner's Finding: LAMBROPOULOS Andrea

34y · Male·hypoxic-ischaemic encephalopathy following laparoscopic bariatric surgery with iatrogenic spleen and liver damage on a background of ischaemic heart disease, obesity and obstructive sleep apnoea

Andrea Lambropoulos, a 34-year-old man with morbid obesity, sleep apnoea, and ischaemic heart disease, died following sleeve gastrectomy. He was admitted to HDU rather than ICU post-operatively. In HDU, he experienced repeated episodes of low oxygen saturation (33 alarms over 40 minutes including 3 crisis alarms) due to sleep apnoea and post-operative narcotic effects. Despite clear monitoring data, nursing staff failed to respond appropriately to alarms, assuming false readings due to probe displacement. The coroner found the death was preventable through proper nursing care, early MET escalation, and appropriate alarm response. Key clinical lessons: (1) understand pulse oximetry reliability by checking plethysmograph waveforms rather than assuming false readings; (2) respond promptly to all desaturation alarms in post-operative patients with sleep apnoea; (3) escalate early to MET/ICU when desaturation patterns indicate inadequate oxygenation.