Doctors performing surgery on a high-risk patient in Gisborne were not aware of health information that could have made the woman an unsuitable candidate for the operation. Janet Roberta Milner died, aged 50, at Waikato Hospital on July 18, 2021, days after she had undergone bariatric surgery in the form of a laparoscopic sleeve gastrectomy stomach removal at Chelsea Private Hospital in Gisborne. Laparoscopic sleeve gastrectomy is keyhole surgery where the bulk of the stomach is removed, leaving a slender “sleeve” of stomach in place. It makes a person feel full with only a small amount of food by physically restricting the amount the person can eat at any one time. Coroner Bruce Hesketh, in his findings released today, said Milner was “not an appropriate candidate for bariatric surgery” in view of her significant comorbidities, extremely high BMI (body mass index), mixed cardiac disease and having a mechanical heart valve that was incorrectly identified to both the surgeon and anaesthetist. “Had they known, I am satisfied that a different post-operative care plan would have been arranged.” Private surgery sought Milner had moved back from Christchurch to her birthplace of Gisborne in 2018. She consulted with her GP, Dr Mark Devcich of Waikohu Health Centre, in December 2020 about laparoscopic sleeve gastrectomy surgery. Devcich recorded that she fell just outside of the criteria for being accepted for the surgery in the public health system. Milner weighed 167kg at the time of her death. Her BMI was recorded as 60kg/sq m. Obesity is defined as a BMI above 30. Severe or extreme obesity is any BMI over 40. She decided to have the surgery privately and made an appointment with Peter Stiven, a general, laparoscopic and upper GI Surgeon and endoscopist in Gisborne, after consulting with John Fleischl, a general, laparoscopic and bariatric surgeon in Hastings. A letter from Fleischl, a referral letter from Dr Devcich and Milner herself in her consultation with Stiven all incorrectly stated her mechanical heart valve was an aortic valve. “I am satisfied the weakness in the chain of these events was Dr Devcich not reviewing his notes properly and Ms Milner providing Mr Fleischl the incorrect description of her heart valve,” Coroner Hesketh wrote. “Despite the lack of fixed rules around referrals, this case is a reminder of the importance of any medical professional reviewing the past medical history of a patient to ensure a full medical history is recorded.” Coroner Hesketh said the knowledge of the type of valve would have had “direct bearing” upon the post-operative care to be administered. He also said a cardiologist had reviewed Milner in 2018, in Christchurch, before she returned to Gisborne. “Dr Devcich should have reviewed his patient notes properly and referred to that cardiac report in his referral to Mr Stiven so that he and Dr Hirling [the anaesthetist] would be aware of all the risk factors (Dr Devcich accepts this adverse comment). “Given the plan Mr Stiven had in terms of Ms Milner’s surgery and recovery and now being aware of the true extent of her past medical history, I am not satisfied Janet Milner was an appropriate candidate for the surgery on 14 July 2021 in terms of that plan. “That is not a criticism of either Mr Stiven or Dr Hirling, they did not know Ms Milner was supporting a Mitral valve.” Lack of record-keeping ‘unacceptable practice’ Milner had her surgery at Chelsea Hospital in Gisborne on July 14, 2021 and no issues were apparent the day after. The coroner was satisfied Chelsea Hospital staff were all experienced in laparoscopic sleeve gastrectomy surgery and care. Chelsea Hospital had been offering the surgery for over four years at that time and usually completed 12-14 procedures a year. By the late afternoon of July 16, however, Milner’s heart rate became erratic and she experienced low oxygen levels. “By 9pm, Ms Milner was complaining of a heaviness in her chest and was coughing up mucous,”...