Coroner's Court of Western Australia

Inquest into the Death of Anne RZEPCZYNSKI

Inquest into the Death of Anne RZEPCZYNSKI

Delivered on :14 June 2018

Delivered at : Perth

Finding of : Coroner King

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased at the time of her death was a 59 year old woman who lived with her husband and their two sons.

The deceased had an aggressive cancer in the bile ducts, requiring surgical excision. A stent was inserted in the bile ducts and surgery was booked to take place 10 days later.  The surgery was postponed twice, eventually taking place 20 days after the stent was inserted.

Post-operative assessment showed that the cancer had been entirely removed but a small bleed had occurred during the operation. Further surgery to fix the bleed took place on the next day, and it is likely that the operation caused a bile leak by disturbing sutures placed on the previous day.

The bile leak led to infection in the abdomen. The infection was treated conservatively with antibiotics and the treatment appeared to be successful, but about three weeks after the second operation, the deceased’s condition deteriorated, with ongoing abdominal infection and respiratory failure from pleural infusions.  She died about four weeks later.

The focus of the inquest was on the delay of the initial operation to remove the tumour and on the deceased’s post-operative care, including the appropriateness of the nutrition provided to the deceased.

The evidence indicated possible shortcomings in relation to nutritional issues, but the Coroner was not able to conclude whether those shortcomings contributed to the deceased’s death.

Catch Words: Cholangiocarcinoma : Median Hepatectomy : Surgical Postponements :  Post-operative care : Patient Dietary Intake : Natural Causes

Last updated: 30-Apr-2019

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