Coronial findings – Margaret (Margot) Pegum

The Coroner made two recommendations today, addressed to the Australian and New Zealand Metabolic and Obesity Surgery Society:
1 That consideration by given to developing guidelines concerning intragastric balloon procedures, covering patient selection and exclusion criteria, indications and contraindications, risks, and appropriate follow up care and advice;
2 That consideration be given to compiling a data registry with details and outcomes for all bariatric patients, aimed at providing clinicians and prospective patients with evidence-based information to guide decisions about the various bariatric options.
Coroner Ryan has today published her findings into the circumstances of my mother’s death. She has found that the decision to offer an intragastric balloon to my mother was a significant error of judgment, given the manufacturer’s published information and available peer-reviewed research literature. As the Coroner noted, the doctor involved has quite properly conceded that his decision was unwise. The Coroner also focused on the adequacy of information given to my mother about intragastric balloons and about post-operative symptoms.
Our aim in bringing attention to what happened to my mother, Margot, has always been focused on preventing another family from enduring what we have as a result of her death. For that reason the Coroner’s recommendations are of the greatest significance.
I strongly support both of the Coroner’s recommendations; however I am concerned that the guidelines and the data registry to be produced by the Australian and New Zealand Metabolic and Obesity Surgery Society may only a first step. For that work to be of wide and enduring value to patients and their families I would like to see the Australian Health Practitioner Regulation Authority take responsibility for the review and roll out of the guidelines and the data registry information, in a similar way as has been done for the cosmetic surgery industry.
The loss of my mother is a high price for us to have paid, but hopefully part of her legacy will be the improvement of standards for the increasing number of people who wish to take steps about their weight in order to improve their life and health.
We wish to thank the Coroner and all involved for their work on behalf of our family.
Prior news report:
For interviews please contact 02 8324 7505; Mr James Pegum may also be contacted directly on 0416 235 849.
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