Coroner's Court of Western Australia

Inquest into the Death of Justin DOBSON

Inquest into the Death of Justin Dobson

Delivered on : August 2023

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Justin Dobson was a 46 year old man who underwent a routine haemorrhoid operation at Osborne Park Hospital in July 2019. He unexpectedly developed profound sepsis and died two days after the operation. The cause of death was given as sepsis following haemorrhoidectomy.

An internal review of the medical care, and review by independent experts, reached the conclusion there was evidence of the sepsis as early as 11.00 am on 18 July 2019, and certainly by 3.00 pm, but the signs were not recognised, and instead his symptoms were attributed to other causes. The consultant surgeon who had performed the operation was not informed of Mr Dobson’s deterioration, or indeed the fact he had not been discharged home as expected, until late that evening when a MET Call was made. By that time, Mr Dobson was profoundly unwell. The surgeon directed Mr Dobson be given antibiotics and transferred to Sir Charles Gairdner Hospital (SCGH). On arrival at SCGH, Mr Dobson was assessed and sepsis was suspected. He underwent exploratory surgery to try to identify the source of the sepsis, but no source could be identified. Mr Dobson received intensive care, but his condition continued to deteriorate and he died at SCGH on the morning of 19 July 2019.

An inquest was held on 15 to 17 March 2023. The inquest took into account the results and recommendations of a root cause analysis and independent expert review of the case. The general consensus of the experts was that Mr Dobson’s death was potentially preventable with earlier treatment, or at least he would have had the best chance of survival. The failure to identify a deteriorating patient and make a MET call resulted in a delayed transfer to SCGH and likely contributed to the death. Evidence was provided that most of the recommendations of the root cause analysis had been implemented. Therefore, the Coroner found there were no further recommendations required to be made.

The Deputy State Coroner found that death occurred by way of natural causes.

Catch Words : Discretionary Inquest : Haemorrhoidectomy : Sepsis  : MET Call : Observation Chart

Last updated: 18-Sep-2023

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