Medical staff should never have operated on woman who died after eye surgery: coroner

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Medical staff should never have operated on a mother who suffered complications during a cataract procedure and died, a coroner has found.

Cherie Virginia Pearl Guest’s family were never adequately warned about the grave health risks the procedure on her eyes posed to her before the 61-year-old underwent the two-part surgery.

Former childcare worker Cherie Guest’s death was the subject of a coronial inquiry.

Guest developed difficulty breathing and went into respiratory distress during the procedure at Victoria Parade Surgery Centre (VPSC) on August 12, 2018.

Coroner Katherine Lorenz on Thursday found medical staff – including Guest’s surgeon – should not only have known and investigated the risks and relayed them to the patient and her family, but should never have gone ahead with the procedure.

Instead, as Guest repeatedly pleaded not to be laid back down – because when she did so, she struggled to breathe – the coroner found ophthalmologist Joseph San Laureano continued to operate.

“I am satisfied that Mrs Guest’s death was preventable and failure to cancel the surgery caused Mrs Guest’s death,” Lorenz said.

The coroner said all three medical staff involved – a surgeon, anaesthetist, and the centre’s director of nursing – failed in their duty of care.

Medical records, she said, later revealed anaesthetist Fabian Purcell, unbeknown to the Guest family, had categorised the patient’s risk level as being so high that performing surgery on her at all was a breach of the clinic’s policies.

A clinical review of Guest’s death, known as a root cause analysis, was later found to contain a litany of errors and omissions about what occurred in August 2018.

Cherie Guest’s daughter, Angela Guest, leaves the Coroners Court on Thursday.Credit: Joe Armao

Guest’s daughter, Angela, who was present with her mother on the day of the procedure, said she believed the clinic’s report amounted to a cover-up. The family now plans to launch legal action against the clinic.

“There were two very separate conversations had that day. There were the conversations we were having with the medical practitioners where they were reassuring my mother and saying everything was fine,” Angela Guest said outside the hearing.

“Then there was a separate conversation between the medical practitioners, where they were talking about risks, where they were talking about cancelling the procedure. A lot of unnecessary risks were taken. Mistakes were made.”

In 2017, Guest’s GP referred her for a diabetic eye check with San Laureano. During a review the following year, he recommended she undergo cataract surgery on both eyes, beginning with her left.

During the consultation, the Coroners Court heard, San Laureano said he could perform the procedures at the VPSC, which had the latest laser eye technology not available in the public system.

But the surgery required Guest to lie flat, and when her daughter raised concerns about her mother’s inability to do so without struggling to breathe, it was recommended a two-part procedure take place.

Cherie Guest and daughter Angela.

The mother, who used an oxygen tank, had a documented history of respiratory complications and required 24-hour supplemental oxygen support. She had also had previous hospital admissions for respiratory failure.

The coroner heard Guest also had documented reactions to medications including anaesthetic drugs Lignocaine and Xylocaine.

During the practice run on August 8, 2018, Guest was able to lay flat for five minutes, but a nurse noted the patient quickly experienced dizziness.

No formal anaesthetic assessment or testing of oxygen saturation was used on the day and Guest’s daughter later raised concerns that her mother “changed colour upon being laid flat”.

Cherie Guest had a documented history of respiratory failure.

Purcell, the anaesthetist, subsequently determined the 61-year-old was a high-risk patient and told the surgeon he was no longer willing to take part, and instead offered to remain on standby as “back up”.

The risks, Purcell said, were “profound” and he rated Guest as having a risk rating of ASA-4 and was a risk of respiratory failure who would require critical care if she deteriorated. The VPSC’s internal policy restricts them from performing surgery on patients with a risk level higher than ASA-3.

The coroner said San Laureano proceeded with the surgery despite neither he nor Purcell informing Guest’s family of their conversations.

During the procedure, Guest became visibly unwell and her oxygen levels dropped to 59 per cent.

When her family asked if the second part that day could be postponed, they were told doctors had no other choice but to proceed.

Nearby staff said they repeatedly heard Guest saying she “did not want to lie down again”.

San Laureano continued with the second part of the procedure, but due to Guest’s breathing difficulties, her health declined and she was intubated.

She was taken to St Vincent’s Hospital’s intensive care unit, where she died five days later.

The coroner found that because staff failed to tell the Guest’s family of the known risks involved in her procedure, it meant she never gave informed consent for it to take place. Lorenz said the surgeon also administered a drug the patient explicitly told him she was allergic to.

Lorenz found Guest was medically unfit for surgery, and any cataract surgery that could have been performed should have occurred at a public hospital with oxygen monitoring and an intensive care unit.

The procedure, she said, also should have been done manually and not with the laser machine, which would have allowed Guest to sit upright.

The coroner noted a root cause analysis of Guest’s death, completed by VPSC’s chief executive and director of nursing, Tim Puyk, and supplied to Safer Care Victoria for review, also contained errors and omissions about what occurred.

This, the coroner said, included a false statement that Guest’s family pressured the clinic to perform the surgery and were aware of the risks involved.

Lorenz said this was in stark contrast to the evidence heard at the inquest.

The VPSC’s website describes itself as a “centre of excellence” designed to provide the best possible surgical outcomes for patients.

Guest’s family said outside court they had established two awards at a suburban primary school honouring the former childcare worker, for children who showed resilience and significant achievements.

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