Coroner's Court of Western Australia

Inquest into the Death of Lee MILCHERDY

Inquest into the Death of Lee MILCHERDY

Delivered on : 23 June 2022

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : No

Orders/Rules : No

Suppression Order : N/A

Summary : Ms Lee Milcherdy (Ms Lee Milcherdy) was 75-years of age when she died at Jacaranda Lodge on 28 February 2019, from complications following an endoscopic retrograde cholangiopancreatography (ERCP) to remove a gallstone it was suspected she had.

Ms Milcherdy had been admitted to Joondalup Health Campus (JHC) on 10 October 2018, with a history of vomiting, diarrhoea and abdominal pain.  An ultrasound suggested she had a gallstone, and she was booked to have a ERCP to remove it at Sir Charles Gairdener Hospital (SCGH).  However, prior to being transferred to SCGH for the ERCP, Ms Milcherdy underwent a type of MRI scan at JHC known as a magnetic resonance cholangiopancreatography (MRCP) which showed she did not have a gallstone.

Due to a communication error, the results of Ms Milcherdy’s MRCP were not passed on to SCGH before she underwent the ERCP.  For that reaons, the procedurewent ahead as had been planned on 15 October 2018.  Following the ERCP, Ms Milcherdy developed a number of serious complications including pancreatitis, and despite ongoing medical treatment, including further surgery, her condition deteriorated and she eventually died.

The Coroner concluded that when considered globally, Ms Milcherdy’s care and treatment had been substandard and that after her negative MRCP result, Ms Milcherdy was not a candidate for an ERCP.  The coroner said that the fact that Ms Milcherdy had undergone an unnecessary procedure, from which she developed serious complications that ultimately resulted in her death, was clearly deeply regrettable.

The coroner noted that since Ms Milcherdy’s death, both JHC and SCGH had made changes to their respective procedures designed to address the communication errors which led to Ms Milcherdy’s MRCP result not being given to SCGH.  In light of these changes the coroner decided against making any recommendations, but urged clinical staff at both JHC and SCGH to remain vigilant when dealing with patients undergoing an ERCP.

Catch Words : Death in Hospital: Communication breakdown: Unnecessary procedure: Misadventure

Last updated: 3-Jul-2023

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