Inquest into the death of William Edmunds

Case Number: 2019/37940

Findings Date: 9 March 2023

Magistrate: Erin Kennedy

CORONIAL LAW | cause and manner of death; surgical error; Hartmann’s procedure; ileus; stoma; iatrogenic mechanical bowel obstruction; peritonitis; open disclosure; open disclosure at the time of error being discovered; involvement of original surgeon in any additional treatment

Responses

Recommendations

The Health Care Complaints Commissioner

That the brief of evidence, transcript of evidence given at the inquest, and a copy of the findings in the Inquest into the death of William Edmunds be forwarded to the Health Care Complaints Commissioner (HCCC) to consider and investigate the care and treatment that Dr Liu-Ming Schmidt provided to Mr Edmunds between 7 November 2019 – 2 December 2019 at the Albury Campus of Albury Wodonga Health to determine whether any disciplinary action is required.

The Executive of Albury Wodonga Health

That consideration be given to the implementation of a surgical audit tool to facilitate the capture and recording of data in real time in respect of surgical outcome.

The Executive of Albury Wodonga Health and the Australian Commission on Safety and Quality in Health Care

That consideration be given to the implementation of a policy, or promulgation of a directive, that mandates the presence of a witness at the initial disclosure of a medical complication where the disclosure is made by the health practitioner who made the error. The witness would be equal to, or more senior than, the practitioner who made the error.

That consideration be given to the implementation of a policy, or promulgation of a directive, which requires, where practicable, that a patient who has experienced an avoidable medical error be informed that they may decide whether the health practitioner who made the error has further involvement in their care.

Related content