Inquest into the death of Sean Montgomery

70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia

70-year-old Sean Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner identified multiple significant failings: the surgeon Dr F. failed to adequately review CT imaging, which clearly showed organ herniation, leading him to underestimate surgical complexity and risk. He failed to provide adequate informed consent and produced an inadequate operation report that didn't document surgical difficulties or organ injury. Postoperatively, there were missed opportunities for earlier recognition of deterioration (inadequate observation frequency, delayed recognition of severe metabolic acidosis, acidosis overnight). Most significantly, there was an inexplicable delay in returning Mr Montgomery to surgery after his condition deteriorated—over 4 hours elapsed before he reached the operating theatre, during which his organs suffered progressive ischaemic injury. The private hospital lacked emergency takeback protocols and on-call anaesthetist cover. Surgical technique caused extensive organ damage (liver, bowel), which combined with the delayed return to surgery and failure of mesh repair, ultimately proved fatal. Preventive measures should include adequate pre-operative imaging review, detailed operation reporting, timely escalation protocols, and emergency surgical capacity.