WA woman’s death due to ‘misadventure’

A woman who died after a case of misdiagnosis still may not have survived if doctors had correctly identified her ailments sooner, a West Australian coroner has found.


Julissa Teresa Gilbert, 57, was an obese smoker with a history of hypertension, arthritis, asthma and chronic obstructive airways disease.

On September 17, 2008, she ate a hotdog for lunch, felt abdominal pain and vomited that night.

She visited Geraldton Regional Hospital and had an appendectomy the next morning.

The doctor who saw Ms Gilbert after her surgery believed her subsequent hypotension was due to septic shock and ordered more fluids with increased Aramine infusions.

But Ms Gilbert died a little over two hours later from an intra-abdominal haemorrhage.

In her findings, Deputy State Coroner Evelyn Vicker noted that because the doctor determined Ms Gilbert was suffering from septic shock rather than an internal haemorrhage, he considered it a medical problem rather than a surgical or anaesthetic problem.

As a result, he did not consult the surgeon or an anaesthetist, who may have offered a different perspective, Ms Vicker said.

“This may have presented an alternative view for the deceased’s deterioration, but may still have been too late to have altered the outcome,” she said.

The coroner noted there was some doubt about whether there would have been enough time to supply Ms Gilbert with sufficient blood products and return her to surgery to stem the bleed and save her.

Given how rapidly her condition deteriorated, it was impossible to predict whether a correct diagnosis earlier would have saved her, Ms Vicker said.

“The deceased needed blood or blood products in sufficient quantities to replace the loss and provide appropriate perfusion, and surgery to correct the source of the blood loss, if it could be located,” she said.

Ms Vicker noted there had been changes made to medical practices since 2008, including improvements in the management of deteriorating patients.

She concluded that Ms Gilbert died due to misadventure.