Surgery is not without risk and having an operation is always a balancing act, a coroner has warned.
Dunedin woman Grace Sullivan died in the city's hospital on September 19, 2000.
She was operated on in May by Associate Professor Magnus Thorn to treat a fistula, and had a follow-up operation on July 4 after becoming increasingly unwell.
In his findings, issued today, Otago Southland coroner David Crerar noted Gary Sullivan - Grace Sullivan's son - said he and his mother had been told surgery was ''likely to be 99.9 per cent effective''.
The coroner said all surgery was a risk, but risks had to be balanced against rewards. If successful, the surgery would have given Grace Sullivan a better quality of life, and he was satisfied the risks of surgery had been identified.
''Although there may have been some suboptimal technique, it cannot be demonstrated that this was necessarily directly related to the circumstances of the death. In fact, the surgery of July 4, 2010 revealed complications which were unable to be recognised, or known, earlier.''
Grace Sullivan suffered chronic illnesses which increased the risk of surgery, the coroner said. Her death was caused by sepsis, multi-organ failure and heart disease.
''Although Southern District Health Board and Professor Thorn may have done better for Grace Sullivan, I have no evidence upon which to base a finding that either fell substantially below normal and appropriate standards of care.''
The coroner noted Gary Sullivan's complaints about the DHB's failures in communicating with him.
The coroner said communication issues did not fall under his remit of establishing a cause of death, but hoped the DHB would learn from the incident and ensure such issues did not recur.
- D Scene
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