Coroner's Finding: Briffa, Gennette Anne

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Simon Cooper, Coroner, having investigated the death of Gennette Anne Briffa Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Gennette Anne Briffa; b) Mrs Briffa died due to breakdown of oesophageal/gastric anastomosis following laparoscopic revision of gastric bypass; c) The cause of Mrs Briffa’s death was sepsis; and d) Mrs Briffa died, aged 73 years, on 30 January 2022 at the Royal Hobart Hospital, Hobart, Tasmania.

In making the above findings I have had regard to the evidence gained in the investigation into Mrs Briffa’s death. The evidence includes:

• Tasmanian Health Service – Death Report to Coroner;

• Police Report of Death for the Coroner;

• Affidavit confirming identity;

• Affidavits – Albert Briffa, sworn 18 and 21 March 2022;

• Affidavit Nazanin Hosseinpour, sworn 21 March 2022 (and photographs);

• Report – Dr Christopher Lawrence, Forensic Pathologist;

• Report – Dr Anthony Bell, Medical Advisor to the Coronial Division;

• Medical Records – Tasmanian Health Service;

• Medical Records – Churchill Avenue Medical Centre;

• Medical Records – Hobart Private Hospital; and

• Précis of medical records – Clinical Nurse Specialist Ms L Newman.

Background Mrs Briffa’s extensive medical history included a cholecystectomy, colonoscopies and gastric band surgery.

In June 2021, her gastric band was removed by Dr Patiniotis, without complication, at the Hobart Private Hospital (HPH). She underwent a colonoscopy on 12 August 2021.

On 17 August 2021, Mrs Briffa was admitted to the HPH for a laparoscopic single anastomosis gastric bypass, again performed by Dr Patiniotis. Her recovery was complicated by haematemesis, but by 23 August 2021, she had recovered to enable her discharge home.

Post operatively her recovery was slow. Mrs Briffa attended the HPH with constipation on 17 September 2021, and then at the Royal Hobart Hospital (RHH) Department of Emergency Medicine (DEM) with dehydration and vomiting on 2 October, being discharged in the early hours of 3 October 2021.

On 8 October 2021, Mrs Briffa returned to the RHH DEM where she was diagnosed as suffering from a right lower leg deep vein thrombosis. She was discharged the following day with apixaban.

Mrs Briffa returned to the HPH on 26 October 2021 with nausea and vomiting. She was admitted, treated conservatively, and thought to have recovered sufficiently to warrant her discharge on 12 November 2021.

Dr Patiniotis continued to review Mrs Briffa. He saw her on 26 November 2021 when he noted her recovery was slow. Notes of a further review on 21 December 2021 again indicate her recovery was slow.

Three days later, on 24 December 2021, Mrs Briffa was admitted, again to the HPH and again with dehydration and constipation.

Surgery followed on 27 December 2021 for the positioning of a naso-enteric tube and manual disimpaction of her bowels. Post-operatively, Mrs Briffa was deconditioned, weak and exhausted. She required assistance with mobilising and her nausea and vomiting continued.

On 4 January 2022, Dr Patiniotis noted Mrs Briffa’s legs were swollen. The following day, blood tests showed evidence of renal and liver dysfunction. Dr Patiniotis authorised Mrs Briffa’s discharge on 6 January 2022.

She continued to be most unwell.

Circumstances of death Mrs Briffa returned to the HPH, for the final time, on 21 January 2022. Upon admission, the diagnosis recorded in her notes was “malnourished post gastric bypass”.

On 24 January 2022 she underwent laparoscopic reversal of the gastric bypass with an intraoperative gastroscopy. Post operatively Mrs Briffa was reportedly troubled by abdominal pain, hypotension and haematemsis.

During the early hours of 25 January 2022 a MET call was made and she was transferred to the critical care unit at the HPH. Mrs Briffa received a blood transfusion, remained hypotensive and was recorded as having a significantly decreased urine output. Her limbs were noted to be “markedly oedematous’ and she continued to vomit after any oral fluid intake.

On 26 January 2022, Mrs Briffa passed melaena and the following day she had a period of altered consciousness.

On 28 January 2022, nursing notes indicate that Mrs Briffa was relatively stable but complaining of severe pain on any movement. She remained tachycardic and continued to vomit.

In the early hours of 29 January 2022, Mrs Briffa experienced a rapid increase in abdominal pain and heart rate. Another MET call was made. She was noted to be hypoglycaemic and profoundly hypotensive. At about 7am another MET call was made, following which fluids and antibiotics administered and an urgent CT scan of her abdomen, a CT pulmonary angiogram and an ultrasound on her left arm were all carried out. A small-volume pulmonary embolus was noted along with some free gas and fluid in the peritoneal cavity. The ultrasound of the arm showed Mrs Briffa’s arm was extensively oedematous with increased vascularity but no vascular blockage was seen. She remained profoundly hypotensive.

At 10:37am yet another MET call was made for hypotension (71/47). A RHH intensivist attended and noted Mrs Briffa was critically unwell. Various interventions were put in place and Mrs Briffa was transferred to the RHH ICU in the middle of the day, by which time she was noted to be in acute liver and renal failure. Despite active resuscitation and acute interventions she continued to deteriorate rapidly and died the following day, 30 January 2022 at about 9am.

Investigation The fact of Mrs Briffa’s death was reported in accordance with the requirements of the provisions of the Coroners Act 1995. After formal identification, her body was transferred to the mortuary where highly experienced forensic pathologist Dr Christopher Lawrence performed an autopsy. The autopsy revealed an 8mm perforation at breakdown of oesophageal/gastric anastomosis with pus and altered blood in the gut, the blood Dr Lawrence thought was probably from the stomach.

Dr Lawrence expressed the opinion in his report that the cause of Mrs Briffa’s death was sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopic revision of a gastric bypass. I accept Dr Lawrence’s opinion.

In plain English, I am satisfied that Mrs Briffa died as a complication of bariatric surgery.

In light of this conclusion I asked the Medical Advisor to the Coronial Division Dr Anthony J Bell MD FRACP FCICM to review her treatment.

In his comprehensive report, Dr Bell expressed the opinion that the most likely diagnosis, post-surgery on 24 January was that Mrs Briffa had developed sepsis. Thus his opinion was in accord with Dr Lawrence.

Dr Bell expressed the opinion that once Mrs Briffa showed signs of sepsis, an intensivist should have been involved. He considered that those signs were clear in the aftermath of the surgery and pin pointed the time to involve an intensivist as at the time of the first MET call in the early hours of 25 January 2022.

He said (and I accept): “with appropriate treatment early the small perforation may have healed without surgery. The time to potent intravenous antibiotic is a critical factor… Early renal replacement therapy and circulatory support may [have] been needed”.

Conclusion, Comments and Recommendations The death of Mrs Briffa has proved very challenging to investigate. Her medical conditions were varied and complicated. The management of the various conditions were undoubtedly difficult to manage over a significant period of time.

In addition, all coroners must of course be very mindful of the clarity that hindsight brings to any investigation.

Having regard to these two caveats, I am satisfied that the course of her treatment until the surgery on 24 January 2022 was appropriate and that the numerous issues which emerged were dealt with well. The surgery on 24 January 2022 was, I consider, necessary.

However, the response to Mrs Briffa’s post-surgical complications on and from the early hours of 25 January 2022 was, in my assessment, below an acceptable standard.

There was an apparent failure to identify with a degree of certainty that she had developed sepsis and the involvement of an intensivist was too late to alter the ultimate outcome for Mrs Briffa.

I do not consider that the circumstances of Mrs Briffa’s death require me to make any formal comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

I convey my sincere condolences to the family and loved ones of Mrs Briffa.

Dated: 25 July 2024 at Hobart in the State of Tasmania.

Simon Cooper Coroner