Inquest into the death of Christopher Glen Essery

74y · Male·Sepsis secondary to fistulating Crohn's disease and post-surgery complications following surgical treatment on 24 January 2019

Christopher Essery, a 74-year-old man with complex fistulating Crohn's disease, died from sepsis following surgery on 24 January 2019. He was transferred to Princess Alexandra Hospital (PAH) on 31 August 2018 for specialist management of enterocutaneous fistulas and intra-abdominal collections. Critical systemic failures occurred: (1) no early post-admission colorectal surgical consultant review despite this being the stated purpose of transfer; (2) the assigned surgeon (Dr Gourlas) went on extended leave without reviewing the patient or formally handing over care; (3) no single consultant took responsibility for his care during 12 weeks of absence, creating confusion about accountability; (4) medical optimisation was prolonged without review of previous unsuccessful optimisation at Cairns; (5) a secondarily-infected mesh from previous hernia repair was not recognised or considered in management decisions despite radiological evidence. These failures delayed definitive surgical consideration and contributed to progressive clinical deterioration. Clinicians should ensure formal handover and continuity of care for complex patients when extended leave is planned, and should review prior treatment failures before commencing similar interventions.