Mark Plumb underwent elective gallstone removal surgery.
Following the surgery, he deteriorated quickly and became
septic, passing away the following evening.
Mr Plumb's surgeon, Dr Anderson, failed to take an
alternative care procedure when conservative methods began to fail,
which led to his rapid demise.
The coroner made recommendations as to improvements in
procedures for nursing staff in recognising a deteriorating
patient, with emphasis placed on improving communication and pain
Mark Plumb passed away on 23 October of 2014 as a result of
multiple organ failure and sepsis with peritonitis and
pancreatitis, among other complications, stemming from an elective
procedure to remove a gall stone.
A 76 year old man in relatively good health, with his only known
medical condition being lupus, Mr Plumb underwent gall stone
removal at the Friendly Society Private Hospital in Bundaberg on 19
September 2014. Post-operatively and overnight, his condition
deteriorated quickly and he became septic. By 5:30 the following
morning, Mr Plumb was experiencing acute renal failure and
peritonitis, and a decision was made for the deceased to be
transferred to the Wesley Hospital in Brisbane for urgent
management by way of the Royal Flying Doctor Service.
At Wesley Hospital, Mr Plumb underwent emergency surgery, during
which it was found that the bile and pancreatic duct were partially
disconnected from the duodenal wall and were leaking into the
abdomen. Post-surgery, Mr Plumb remained unwell and his prognosis
worsened, with a decision subsequently being made for palliative
This case was referred to Queensland's coroner's court
after a review of the deceased's medical records and an expert
review that raised concerns, including "significant
deficiencies" in Mr Plumb's post-operative care. The
issues before the coroner included an assessment of the:
appropriateness of the surgical procedure;
appropriateness of post-operative care (particularly, whether
the deceased's deterioration was recognised and responded to
timeliness of the decision to transfer.
It was found reasonable in all of the circumstances for Dr
Anderson to perform the gallstone removal surgery on Mr Plumb.
There was no evidence to suggest that Mr Plumb was not aware
generally of the risks involved with anaesthetic and the
The coroner's conclusions emphasised the importance of
"systems being in place to recognise and manage a
deteriorating patient". There was no escalation of treatment
in post-operative care despite Mr Plumb's deterioration being
noted for over 11 hours, during which time he became septic.
The coroner considered Mr Plumb's post-operative care to be
adequate until Dr Anderson received results of a CT scan and failed
to physically review Mr Plumb or take a less conservative approach
to his care. While the CT scan did rule out pancreatitis as the
cause of the pain, at this time a perforation became highly
suspected. The failure to physically examine Mr Plumb represented a
missed opportunity to consider alternative management plans, which
could have involved earlier specialist intervention.
The Root Cause Analysis (RCA) undertaken by the hospital and the
five causal statements identified in relation to the death of Mr
Plumb was largely accepted by the coroner. However, the coroner did
make a recommendation that wherever possible, a RCA should involve
relevant members of the treating team and also provide feedback as
to the outcome of the analysis. This practice should be employed
across the board, especially in public hospitals.
Importantly, the coroner found that an earlier recognition of
deterioration and transfer for appropriate care would likely have
improved Mr Plumb's chances of survival from the perforation.
However, the coroner did not express concerns in respect to the
time it took Mr Plumb to be transferred by air bearing in mind the
Mr Plumb's death highlights the importance of having proper
communication systems in place between staff to quickly and
accurately identify deteriorating patients, so a more involved
course of post-operative care can be undertaken. It also provides a
warning about taking a conservative care approach without
adequately examining test results (in this case, a CT Scan) and
physically examining the patient.
The coroner's comments on the RCA undertaken by the hospital
also provides a suggestion as to best practice when analyses of
this kind are conducted.
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