Inquest into the death of Margaret June Mariani

Case Number: 2019/00219251

Date of Findings: 14 August 2025

Magistrate: Deputy State Coroner, Joan Baptie

CORONIAL LAW – complications of cholecystectomy surgery – grossly inadequate care and treatment provided at Forster Private Hospital – inadequate monitoring and poor record keeping of observations – delay in notifying surgeon of deterioration – deficiencies in practices and procedures

Responses

Recommendations

1. That Forster Private Hospital give consideration to providing further training to all staff (including Visiting Medical Officers (VMOs), Career Medical Officers (CMOs)/Locums and nursing staff) to ensure that the current policies and procedures are being adhered to with respect to documentation of patient’s care.
2. That Forster Private Hospital give consideration to amending its policies and procedures to ensure that there is greater clarity in respect of the expectations of a VMO being contacted by a CMO/Locum or nursing staff and in what circumstances.