Coroners Act In the matter of Coronial Findings and Recommendation into the Death of Ms Souzana Afianos pursuant to section 46B dated 1 January 2004
Tabled paper 1394
Tabled Papers for 9th Assembly 2001 - 2005; Tabled Papers; ParliamentNT
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There was a large amount of blood in the abdomen. His estimate was two litres. There was significant haemorrhagic tissue in the region of the site where the gastric band was placed. There were signs of older bleeding consistent with the recent surgery and there were tissues which showed signs of infection. In consequence of the absence of any obvious damage to blood vessels and given the presence of the necrotic tissue at the infection site, he concluded that the source of the bleeding was the infection site. There was nothing else to relate the band to the necrotic tissue and infection process other than its placement in the direct area of the infection and the necrotic tissue. There was nothing to connect the placement of the gastric band with damage to any structure which may have caused the bleeding. The formal cause of death in his opinion was a secondary haemorrhage, i.e., a haemorrhage occurring at a later time to, and not related to a physical process. Applied to the current case, it is a haemorrhage not connected with the physical surgery but occurring later as a result of an infection or secondary process. The actual mechanism of death was that as a result of the hypovolaemic shock due to the haemorrhage, the insufficient quantity of blood in the veins resulted in damage to organs, in particular to major organs leading to a shut down of those organs and ultimately death. In his view, the bleeding must have been present for a matter of hours to build up in the abdomen to the extent that it could leak out as it did. Although this was the most likely scenario, he could not 14
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