Published today were the findings of the Inquest into the death of Irene Magriplis [2017] NTLC 008, a decision of Coroners Court at Darwin.

Irene Magriplis died of sepsis caused by bile leaking into her abdomen after elective surgery at the Darwin Private Hospital (a hospital that did not have an ICU). The surgery was to remove a growth adjacent to her bile duct. At the time, Her surgeon was of the opinion that this elective surgery was necessary, but later conceded that it was not.

The findings are of interest for addressing the high risk nature of the surgery such that it should only be carried out after multidisciplinary team review and then in an adequately resourced hospital: [21] – [23].

The Coroner referred the findings to the Medical Board of Australia: [210].

The Coroner also recommended (at [211] – [213]) that:

  • the hospital not permit high risk surgery to be undertaken where it does not have the resources to mitigate those risks.
  • the hospital implement an escalation system to provide a proper rapid team response when the rapid response criteria are met.
  • should the hospital continue to operate a High Dependency Unit that it be properly and appropriately resourced and in conformity with Standard 9 of the National Standards on Safety and Quality in Health Care and the Guidelines of the College of Intensive Care Medicine of Australia and New Zealand.

 

 

 

 

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