Although the Coroner ultimately found that Ms Campbell’s death was caused by an inappropriate post-operative discharge, the findings are notable for their extensive criticism of the treating surgeon’s clinical records. The findings serve as an important warning against over-reliance on templated electronic records and pre-filled documentation that does not accurately reflect the care provided.
Although this case concerned conventional templates, the underlying principles apply equally to AI-generated clinical records. A health practitioner’s legal responsibility is to the accuracy and completeness of the final record, regardless of whether it was drafted by a pre-filled template, transcription software or an AI assistant.
Background
Ms Campbell underwent a sleeve gastrectomy in March 2020. After developing persistent gastro-oesophageal reflux disease that was not adequately relieved by medication, she consulted her surgeon in early 2022. A decision was made to proceed with a Roux-en-Y gastric bypass.
The Coroner found that this decision was made with insufficient consideration of conservative management options, including further investigation, dietary management and optimisation of medical therapy.
Following the surgery, Ms Campbell developed an undiagnosed bowel obstruction. Despite ongoing vomiting and concerning fluid balance, she was discharged from hospital and died at home the following day. The Coroner concluded that, had she remained in hospital, her death would likely have been prevented.
Key findings
The Coroner described the surgeon’s clinical record-keeping as “appalling”. Critical consultations were documented only minimally or, at times, not at all. Many records relied on pro forma templates, pre-populated text and drop-down fields that did not accurately reflect the consultation or treatment provided.
Particularly concerning was the finding that some records were not only incomplete but positively misleading. In one instance, the operation record omitted a significant intra-operative event while recording procedural steps that had not in fact occurred.
These deficiencies substantially affected the Coroner’s ability to determine what symptoms Ms Campbell reported, what treatment options were discussed, and what advice she had been given. The reliability of the clinical records was therefore significantly compromised.
The Coroner also questioned the surgeon’s credibility after finding that a template letter prepared in support of Ms Campbell’s application for early access to superannuation contained false statements designed to improve the prospects of approval.
Importantly, while the Coroner was highly critical of the pre-operative decision-making and record-keeping, the primary causal finding was that Ms Campbell’s death resulted from the inappropriate decision to discharge her despite clear post-operative warning signs.
Key takeaways
Beyond the specific facts of this inquest, the decision highlights several practical takeaways for health practitioners.
First, clinical records must accurately reflect what occurred during the consultation. While electronic templates and standardised documentation can improve efficiency, they should never replace contemporaneous, patient-specific records. Pre-populated entries that are left unedited may create records that are not simply incomplete, but inaccurate or misleading.
Secondly, poor record-keeping can significantly affect a practitioner’s credibility. Where clinical records cannot be relied upon, courts may be unable to determine what advice was given or what clinical reasoning underpinned important decisions.
Finally, the case demonstrates that documentation failures often become a central issue in litigation and coronial investigations, even where they are not themselves the direct cause of a patient’s death. Accurate, contemporaneous records remain one of the strongest safeguards for both patient safety and legal defensibility.
Although the Coroner did not refer the surgeon to Ahpra, the findings nonetheless provide a clear reminder that efficiency gains achieved through templated documentation should never come at the expense of accuracy.
The Coroner’s findings can be read in full here.
