Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
I, Rod Chandler, Coroner, having investigated the death of
WITHOUT HOLDING AN INQUEST
Frances PROPOSCH-QUARRELL ("Mrs Proposch-Quarrell") died on 6 July 2004 at the Royal Hobart Hospital in Hobart ("the RHH").
Mrs Proposch-Quarrell was born at Ouse on 25 June 1943 and was aged 61 years. She was a retired sales manager and lived separately from her husband.
I find that Mrs Proposch-Quarrell died as a result of multiple organ failure and disseminated Aspergillus infection following perforation of the small intestine after laparoscopic and open gastric banding for obesity.
At the time of her death, Mrs Proposch-Quarrell was in the care of medical practitioners at the RHH.
Circumstances Surrounding the Death:
Mrs Proposch-Quarrell had long suffered from morbid obesity. In about 1990 she had undergone a gastric stapling procedure which initially led to some weight reduction. However, she subsequently regained weight so that by May 2004 her weight was 105 kgs. Her body mass index at that time was over 40, well within the morbidly obese range.
On 18 June 2004, Mrs Proposch-Quarrell was admitted to the Hobart Private Hospital for laproscopic stomach banding to be carried out by surgeon Mr Stephen Wilkinson on that day.
The laproscopy was commenced at 1.45pm. Extensive dense adhesions were encountered (presumably a result of the previous gastric stapling) which could not be freed sufficiently to allow an adequate working space. Consequently the laporoscopy was abandoned and the procedure converted to open surgery. Mr Wilkinson describes the operation in these terms;
"The previous midline incision was then opened. There was an extensive division of adhesions between the stomach and the small bowel and liver. A retrograde dissection was carried out at the gastro-oesophageal junction. This was not difficult and was guided by the presence of an oro-gastric tube. The gastric band was positioned and placed in the appropriate position and the tubing connected to the injection port which was then placed anterior to the left anterior rectal sheath. In order to close the abdomen further extensive adhesions had to be cleared from the right abdominal wall in the area of the incisional hernia. The right abdominal wall was extremely weak and required a large amount of continuous looped DDS suturing to provide closure and repair of the incisional hernia. During the clearance of adhesions there was no indication at all of any bowel damage and no suspicion that any bowel damage had occurred. There was no intestinal leakage. The bowel was thinned in one area and this was oversewn and strenghthened with 2.0 chromic catgut but there was no luminal perforation in any area which was identified at the time of her primary surgery. The remainder of the wound closure was routine"
The surgery finished at 5.15pm and Mrs Proposch-Quarrell was taken for recovery.
From the outset Mrs Proposch-Quarrell’s post operative course was complicated. On the day following her surgery she was slightly confused and complained of abdominal pain which required significant quantities of narcotic analgesia via a patient-controlled pump. Too, she was slightly breathless but she remained afrebile. That afternoon a routine gastrografin swallow was performed. It showed no gastric emptying and nursing staff informed Mr Wilkinson of this by leaving a message on his ‘phone. There is nothing in the records to indicate that Mr Wilkinson attended Mrs Proposch-Quarrell on this day and he is unable to say whether he did or did not.
The records do show that Mr Wilkinson attended Mrs Proposch-Quarrell at 7.00pm on 20 June and he directed that she have another gastrografin swallow the following day. At that time Mrs Proposch-Quarrell’s pulse had gradually increased over the day from 90 peaking at 115. This aside Mr Wilkinson considered Mrs Proposch-Quarrell’s observations to have been essentially normal. Her blood pressure was stable, she remained afrebile, she had opened her bowels and passed urine and she had tolerated oral intake of clear fluids. It was Mr Wilkinson’s plan to review Mrs. Proposch-Quarrell in two days.
Sometime on 21 June nursing staff notified Mr Wilkinson that the gastrografin swallow had indicated successful gastric emptying. During that day the observation chart shows that the pulse remained elevated throughout. Blood pressure decreased from 120/80 at 6.00am to 100/60 recorded at 5.00 pm and later at 8.00 pm. The records show that at 11.45 pm on that day Mrs Proposch-Quarrell removed her mattress from the bed and placed it on the floor asserting that it would be more comfortable for her. She also requested that her family be asked to bring to the hospital a hot water bottle to help relieve her back pain. Nursing staff gave Mrs Proposch-Quarrell oral analgesia for her abdominal pain. It seems that Mr Wilkinson was not advised of these events or of the observation results obtained during the day.
The fourth post-operative day was 22 June. At 6.45 am Mrs Proposch-Quarrell was given further analgesia for abdominal and back pain. Throughout the day she had persistent tachycardia and her blood pressure remained low. At 11.00 pm nursing staff ‘phoned Mr Wilkinson and reported that Mrs Proposch-Quarrell’s surgical wound was oozing a large amount of dark red/brown fluid. The records show that at this time the patient was afrebile and tachycardic.
Mr Wilkinson was undertaking surgery when he received the ‘phone advice from nursing staff. Arrangements were made for Mrs Proposch-Quarrell to be urgently reviewed by the Emergency House doctor. This review was promptly done by a Dr Fitzgerald. Shortly afterwards Mr Wilkinson attended. He noted that Mrs Proposch-Quarrell was hypotensive, tachycardic and with decreased oxygen saturation. However, her chest was clear. She was still afrebile and her abdomen was soft and with bowel sounds, signs contradicative of peritonitis. Too, blood tests showed a normal white-cell count.
Mr Wilkinson ordered a chest x-ray. It showed free subdiaphragmatic gas, a finding indicating the likelihood of leakage from an intra-abdominal viscus. Mrs Proposch-Quarrell was returned to the operating theatre.
At surgery a large volume of intestinal content was found free in the peritoneal cavity from a hole in the small bowel This section of the bowel was removed and a stapled small bowel anastomosis performed. There was no evidence of any further perforation. Mrs. Proposch-Quarrell was then transferred to the Intensive Care Unit (ICU) at the RHH.
In ICU Mrs. Proposch-Quarrell’s condition was critical. She required high levels of medication to support her cardiovascular status, her respiratory state was poor, her kidneys and liver failed, her temperature was elevated and her blood became difficult to clot. Despite no sedation she remained unconscious.
On 24 June 2004 Mrs. Proposch-Quarrell was returned to theatre for an exploratory laparotomy which revealed turbid fluid throughout the peritoneum. However, no gastrointestinal organ damage was visible. Further lavage of the peritoneal cavity was performed and the ‘lap band’ removed. Continuous veno-venous haemofiltration was commenced later that day.
On 29 June 2004 Mrs. Proposch-Quarrell was again returned to theatre. The abdominal wound was debrided and re-packing done. In the first few days of July, after a period of relative stability, inotropic medication was re-commenced for blood pressure support. Mrs. Proposch-Quarrell had a problematic respiratory status and was draining copious amounts of bile-stained fluid from her abdominal wound. As had been the case for most of her ICU admission she had generalised oedema to her limbs and areas of her skin had started to break down and leak serous fluid.
Mrs. Proposch-Quarrell’s medical notes 2 July 2004 indicate that she was at high risk of systemic fungal infection. Blood cultures were taken which later showed that she had disseminated Candida infection. Administration of the anti-fungal agent Amphotericin was commenced.
On 5 July 2004, Mrs. Proposch-Quarrell was again returned to theatre as her condition further deteriorated. Mr Wilkinson detected two further holes in the bowel, one in the distal ileum and a pin hole leakage in the transverse colon. Each was repaired. However, Mrs Proposch-Quarrell continued to deteriorate. A yeast infection was diagnosed in her blood, her stoma became blackened, her blood results were abnormal and she became ‘shut down’.
On 6 July 2004 it was decided, after consultation with her family, that further treatment was futile. Consequently treatment was withdrawn and Mrs. Proposch-Quarrell died at 7.00pm on that day.
A post-mortem examination was undertaken by State Forensic Pathologist, Dr Christopher Lawrence. He reports:
"Mrs Proposch-Quarrell had developed massive peritonitis. The bacterial sepsis and subsequent fungal infection led to a series of organ failures including respiratory, renal and heart failure which ultimately led to her demise. The further breakdown of the wounds was probably exacerbated by the presence of hypotension and disseminated Aspergillus which tends to cause thrombosis of vessels and subsequent infarction".
Dr Lawrence determined that Mrs Proposch-Quarrell had died from multiple organ failure and dissemated Aspergillus infection following perforation of the small intestine after laparoscopic and open gastric banding for obesity.
As part of the investigation of Mrs Proposch-Quarrell’s death independent opinions were sought from Associate Professor Rodney T Judson, a general surgeon and head and neck surgeon in Victoria and from Mr Jon Gani, a general and abdominal surgeon in New South Wales.
Associate Professor Judson has opined that:
- The gastric banding surgery undertaken by Mr Wilkinson was appropriate and was carried out with reasonable care and skill.
- "In the presence of persistent pain, a rising pulse rate and the lack of gastric emptying noted on the first gastrograph swallow I feel it would have been reasonable for (Mr Wilkinson) to have attended his patient on a daily basis or at least make contact with the nursing staff to be reassured as to the progress."
- There is the strong possibility that the delay in establishing the diagnosis and treatment of the bowel perforation would have increased the risk of death resulting.
- The observation chart on 21 June 2004 demonstrates clinical signs of concern with a persistent tachycardia and a slumping of the blood pressure. It is highly conceiveable that had Mrs Proposch-Quarrell been seen by Mr Wilkinson on that day and he’d taken note of these changes that earlier investigation in the form of either chest x-ray or abdominal CT scan could have identified the presence of a significant intra-abdominal complication for which earlier surgical intervention may have significantly improved the chances of survival.
- By not more frequently verifying the abnormal observations and informing the surgeon of the tachycardia, hypotension and persistent pain that there was a delay in the appreciation of the presence of a serious and what subsequently proved to be a fatal intra-abdominal complication.
- It would appear that there were significant clues as to the presence of a serious abdominal problem at least 24 hours if not 48 hours prior to subsequent surgical intervention. It is most probable that this delay did contribute to her death.
Prior to Mr Gani providing his advice, he was provided with copy of Associate Professor Judson’s report along with all other relevant material. Mr Gani has provided these opinions:
- He accepts that there was a delay in diagnosing Mrs Proposch-Quarrell’s perforated bowel but comments, "...the critical question here is could it have been diagnosed earlier had different actions been taken. Almost always post operative visceral or perforation is recognised later than might be the case with retrospect. And once again this appears to have been the case here. Despite reading all the reports, both of medical and nursing staff involved, it is my view that had Mr Wilkinson been able to see Mrs PQ himself on either the afternoon of the 21 June or the morning of the 22 June he is likley to have been suspicious about some post operative misadventure and would probably have organised appropriate imaging and haematological test which may well have led to the earlier diagnosis of visceral injury. I do however understand very well the pressures he has been working under. It is often the case that whilst charts and observations may not make the diagnosis obvious an experienced surgeon can often detect subtle changes in the patient’s status by a combination of these observations and their own clinical acumen."
- "Clearly, with retrospect the changes observed on the 20, 21 and 22 probably do indicate a deterioration in (Mrs Proposch-Quarrell’s) condition though this is obviously much more evident in retrospect than it was at the time. Certainly, some of her findings are not inconsistent with an uncomplicated post operative course..."
- "I believe that Mr Wilkinson’s management of Mrs PQ’s case (post operatively) is completely satisfactory and does not deviate from accepted practice in any way."
Dr Wilkinson accepts that if the bowel perforation had been diagnosed earlier and surgical intervention promptly undertaken then a different outcome may have been achieved for Mrs Proposch-Quarrell. However, he maintains that even in hindsight he is unable to see how he could have made the diagnosis earlier given that it was not until late on 22 June that he became aware of Mrs Proposch-Quarrell’s apparent clinical decline.
It was previously Dr Wilkinson’s usual practice to attend his surgical patients for post-operative review on a daily basis whilst they remained in hospital. However, he acknowledges, because of an increasing workload largely attributable to a shortage of general surgeons in southern Tasmania, that he has modified this practice so that he now ordinarily attends each surgical patient who is not in a high dependancy unit on the first post-operative day and therafter each second day if the recovery seems uneventful. He otherwise relies on nursing staff to advise him of any deviation from the expected post-operative course.
The evidence is not sufficient for me to make a finding on whether Mr Wilkinson did or did not attend Mrs Proposch-Quarrell on 19 June being the day following her surgery. However, it is apparent that he did attend and review her in person at 7.00 pm on 20 June. I accept that at this time her post-operative signs were within normal bounds and that an impending decline in her condition could not have been reasonably anticipated. It was in this circumstance that Mr Wilkinson planned to carry out a further review after two days.
There were some signs presenting on 21 June to suggest that Mrs Proposch-Quarrell’s recovery was deviating from the expected course. Most notably her pulse remained elevated and her blood pressure was low (although I note Mr Wilkinson observes that Mrs Proposch-Quarrell’s diastolic blood pressure was historically low.) Other relevant matters at this time were persisting abdominal pain requiring supplemental analgesia, complaint of back pain and the bizarre conduct involving the removal of the mattress from her bed. The following day abdominal and back pain persisted, Mrs Proposch-Quarrell was tachyardic and her blood pressure remained low. Despite these matters nursing staff did not report any concerns to Mr Wilkinson until late in the evening on 22 June when a large quantity of fluid was observed oozing from Mrs Propoch-Quarrell’s surgical wound.
I recognise that there were other signs and symptoms which contra-indicated cause for concern. Notably, on 22 June Ms Proposch-Quarrell had been able to get out of bed, she had opened her bowels and she had been able to take some fluids. Too, she remained afrebile and her white cell count was normal. I recognise too that clinical judgements are far more difficult to make in real time without the benefit of hindsight. Nevertheless, the overall circumstances of Mrs Proposch-Quarrell’s presentation did, in my view, require nursing staff to report to Mr Wilkinson at an earlier time. Had they done so and had he examined her late on the 21 or during the following morning it is likely, given in particular his considerable experience, that Mr Wilkinson would have at least suspected that something was amiss and initiated further investigations. Had this occurred the need for intervening and immediate surgery would have, in all probably, been realised at an earlier time.
However, whilst I am of the view that earlier surgical intervention would have increased the likelihood of a better outcome for Mrs Proposch-Quarrell I am unable to find, with any degree of certainty, that it would have avoided her eventual death.
It is in my opinion the preferred practice for surgical patients to be reviewed on a daily basis by the treating surgeon whilst they are in hospital. In Mr Wilkinson’s case I accept that because of the demands upon his surgical skills it has been necessary for him to modify his previous practice so that he now ordinarily reviews patients each second day. These circumstances obligate the Hobart Private Hospital to have in place a system which ensures, firstly that nursing staff are adequately trained and experienced to recognise signs or symptoms indicating a patient’s deteriorating condition and secondly that those patients receive immediate medical attention either by Mr Wilkinson or, if he is unavailable, by other suitable medical practitioner. It is my recommendation that the Hobart Private Hospital review its practices to ensure that such a system is in place and operating effectively.
This tragic case is a timely reminder that relatively simple surgical procedures such as gastric banding are not immune from risk. This risk needs to be taken into account by any obese person when deciding upon a weight reduction measure which best suits them.
I conclude by making these formal findings:
- that a full and detailed investigation of Mrs Proposch-Quarrell’s death has been undertaken and there are no suspicious circumstances.
- that Mrs Proposch-Quarrell died at the RHH on 6 July 2004 as a result of multiple organ failure and disseminated Aspergillus infection following perforation of the small intestine after laparoscopic and open gastric banding for obesity.
To end I convey my sincere condolences to the family of Mrs Proposch-Quarrell.
DATED: Friday, 22 May 2009 at Hobart in the State of Tasmania.