A coroner has found that doctors at a private Gisborne hospital waited too long to transfer a woman to higher-level care after she began deteriorating following weight-loss surgery. Reported by Ellen O'Dwyer, RNZ
Janet Milner, 50, died at Waikato Hospital on 18 July 2021, just days after undergoing bariatric surgery at Chelsea Hospital in Gisborne.
In his report, Coroner Bruce Hesketh concluded that Milner was not a suitable candidate for surgery on the day it was performed, citing an incorrect record of her heart valve type and several pre-existing health conditions — including mixed cardiac disease and a very high Body Mass Index (BMI).
The coroner found that Milner’s GP, Dr Mark Devcich, mistakenly recorded her mechanical heart valve as an aorticrather than a mitral valve replacement when referring her for surgery. Although Milner herself had also misunderstood her medical history, Hesketh said it was the GP’s professional duty to ensure all relevant details were accurately included in the referral.
“In this case, that should have included a more detailed medical history of Ms Milner than was recorded, taking into account the nature of the surgery being considered,” Hesketh wrote.
Because of this error, Milner’s post-operative care plan did not account for her true cardiac condition. Her surgeon, Dr Peter Stiven, and anaesthetist, Dr Christian Hirling, later told the coroner that knowing the correct heart valve type would have changed the entire management of her recovery.
“As Mr Stiven has said himself, had he been aware it was a mitral valve, it would have been a game changer,” the coroner noted.
Milner underwent a laparoscopic sleeve gastrectomy on 14 July 2021. Two days later, she developed shortness of breath, a cough, and chest pain — symptoms later linked to cardiogenic and septic shock.
Although staff at Chelsea Hospital noted her declining condition, Hesketh found the decision to transfer her to a higher level of care came too late. A non-urgent ambulance was requested at 10.30 pm on 16 July, and she was moved to Gisborne Hospital ICU around 11.25 pm.
“Ms Milner should have been transferred to Gisborne Public Hospital sooner. The decision to move her to a higher level of care took too long,” the report stated.
Hesketh also criticised incomplete nursing records and the absence of early warning score documentation, calling the post-operative care “sub-optimal.”
A Chelsea Hospital spokesperson expressed condolences to Milner’s whānau and said the hospital had implemented several improvements since the incident.
“We have taken multiple steps to improve our service delivery, including strengthening our admission processes to ensure that surgery in our hospital is as safe as possible.”
Coroner Hesketh made several recommendations, including:
GPs must thoroughly review and accurately record all relevant medical history when referring patients for specialist surgery.
Chelsea Hospital should train staff to record early warning scores consistently, ensuring accurate patient monitoring.
Surgeons and specialists must document all advice, directions, and attendances to maintain complete treatment records.
Milner’s death, the coroner concluded, underscores the vital importance of accurate communication, timely decision-making, and thorough recordkeeping in surgical care.