The State Coroner has been scathing of the treatment and care given to a Perth mother-of-two who suffered "horrific" complications from an elective stomach stapling operation and died six months later.
Julienne McKay-Hall, 46, had the weight loss surgery on November 9, 2007 at St John of God Hospital in Murdoch. The stapling gun used by surgeon Dr Hairul Ahmad misfired during the surgery. The misfire caused a stomach leak, which resulted in Mrs McKay-Hall developing sepsis. Her condition went undiagnosed for three days.
In his findings handed down today, State Coroner Alastair Hope was critical of the "inexcusable failure" by Dr Ahmad and nurses to properly monitor and urgently address the patient's alarming and deteriorating condition.
Mrs McKay-Hall underwent numerous surgeries, spent months in hospital and died in May 2008 after an operation to fix a leaking abdominal fistula at Fremantle Hospital.
Mr Hope described Dr Ahmad's actions, which included not reading critical notes and not coming into the hospital to see Mrs McKay-Hall when a nurse called him about her worsening vital signs, as "grossly inadequate" and referred him to the Australian Health Practitioner Regulation Agency.
Mr Hope said failure to take regular observations of the patient, particularly when she became "close to death", constituted a gross failure by the hospital and nurses involved in her treatment.
Mr Hope said Mrs McKay-Hall's death was a result of "misadventure" and found the "poor quality of treatment and care" by Dr Ahmad and nurses "contributed to her death".
Mr Hope made two recommendations, including calling for improved communication and recording by nurses about patients' abnormal vital signs and for a system of audits to examine if hospitals adequately deal with emergencies.
Mr Hope expressed his sympathies to Mrs McKay-Hall's family for their extreme distress over the "sad, tragic and unnecessary death".
The elective surgery was a relatively new procedure in 2007 and involved removing a large portion of stomach and stapling the remaining part of the stomach. Mrs McKay-Hall, who weighed 111kg before the procedure, chose the drastic action to improve her quality of life.
Outside court, Tanya Watson, lawyer for Mrs McKay-Hall's family, said the family was satisfied with the coronial investigation and that the Coroner had confirmed its suspicions of sub-standard care.
She said the family may consider pursuing compensation.
A spokesman for St John of God Health Care said the hospital remained deeply saddened by Mrs McKay-Hall's death and it co-operated fully with the coronial inquest. He said the hospital would examine the findings carefully and where relevant it would review policies, procedures and practices.
The spokesman said the hospital investigated and suspended Dr Ahmad in 2008 and that suspension remains.