Inappropriate surgery days before the death of a
47-year-old Dunedin woman with Crohn's disease has been
highlighted by Otago-Southland coroner David Crerar.
His formal finding on the death of Claire Adamson, released
yesterday, has been forwarded to the Southern District Health
Board and Medical Council of New Zealand.
Mrs Adamson, a Dunedin seamstress, died at Dunedin Hospital
on March 31, 2011, following surgery from which she developed
a fatal whole-of-body inflammation (sepsis).
She underwent surgery on March 8 and was readmitted to
hospital on March 23 for symptoms suggestive of an
anastomotic leak, in which fluids leak from the failed
closure of an organ cut in surgery.
On March 27, she underwent further surgery for investigation
and repair of the leak, but the operation proved difficult
because of her fragile and inflamed bowel, Mr Crerar said.
''Following this surgery, Claire Adamson developed further
complications and she died,'' he said.
The cause of death was ''multi organ failure and peritoneal
sepsis with a colonic anastomotic leak, on a background of
Mrs Adamson's cousin, Carol Dobbs, a registered nurse, and
other family expressed concern about Mrs Adamson's treatment
at Dunedin Hospital, which resulted in meetings with, and
investigations by, staff.
Professor Magnus Thorn, who had operated on Mrs Adamson,
Dunedin Hospital's clinical leader of general surgery Prof
John McCall and hospital service manager Helen Williams were
involved in dealings with Mrs Adamson's family.
Prof Thorn prepared a report on the case which was forwarded
to Dunedin Hospital's chief medical officer.
Prof Francis Frizelle was commissioned to write an
''Prof Frizelle expressed concern about the operative
management undertaken for the anastomotic leak. In his
opinion, the operation on March 27 was much more extensive
than that which may have been required,'' Mr Crerar said.
His findings included a summary of Prof Frizelle's report,
which stated Mrs Adamson's treatment up to the March 27
surgery was reasonable.
But Prof Frizelle said the operation to repair the
anastomotic leak ''departed from the usual standard of
''There is a range of choices of what would be acceptable and
exactly what is optimum is debatable. However, what was done
departed from what we consider to be reasonable in this
situation,'' he said.
''Bowel anastomotic leakage is a significant complication
with up to one in three patients dying as a direct result ...
it is one of the most common and devastating complications of
all surgery,'' Prof Frizelle said.
Mr Crerar's findings did not detail why the surgery performed
was not acceptable.
He said medical practitioners and surgeons could not be
expected to attain a standard of perfection and all surgery
''I have no evidence that would indicate Claire Adamson was
not advised appropriately of the risks of surgery. Claire
Adamson was cruelly debilitated by Crohn's disease and its
complications, and was seeking a better lifestyle outcome
which it was hoped by her, and by her surgeons, could have
been achieved by the operation,'' Mr Crerar said.
He was satisfied Prof Thorn provided appropriate care to Mrs
Adamson until deciding to operate on March 27.
''I am required to accept the summary of Prof Frizelle about
this, that what was undertaken was not appropriate for the
patient's situation,'' Mr Crerar said.
He recommended his finding be used by the SDHB to inform
clinicians and for training.