Inquest into the death of Lesley ARNDELL

61y · Female·multi organ failure due to abdominal sepsis

Lesley Arndell, aged 61, died from multi-organ failure due to abdominal sepsis after undergoing a Whipple's procedure for pancreatic cancer. Key clinical lessons include: (1) patients with previous bariatric surgery require formal nutritional assessment before major surgery, particularly regarding protein/albumin levels; (2) when sepsis develops post-operatively, antibiotic selection should account for prior antibiotic exposure—Tazocin reuse may have been suboptimal given prior prolonged exposure; (3) medical handover between surgical and ICU teams must explicitly communicate critical medication history; (4) rapid clinical deterioration requires immediate medical review—a 2-hour delay in surgeon arrival without interim medical assessment was substandard; (5) hospital protocols for deteriorating patients must be actively implemented by ward staff and responded to promptly by medical officers. The death likely resulted from anastomotic leak causing peritonitis, compounded by inadequate nutritional optimization and delayed recognition of sepsis.