About one in every 30,000 tonsillectomy procedures results in death.
Carly Liptak, a 12-year-old Palm Harbor girl, apparently was that one.
The medical examiner in Pinellas County has ruled that Carly's death in August was from natural causes. The findings show that she died from complications of tonsillitis. A contributing condition was "cerebellar vascular anomaly."
"Roughly one in every 30,000 tonsillectomy procedures has a fatality," said Bill Pellan, director of investigations at the Pinellas-Pasco Medical Examiner's Office. "This happens to be one of those. It's a sad circumstance."
Mease Countyside Hospital, the facility where the procedure occurred before Carly was transferred to All Children's Hospital, where she died, also has finished its internal investigation into the case.
"We have taken a look at every process that impacted Carly's care," said Beth Hardy, a hospital spokeswoman. "During that internal review, we found no opportunities that would have changed the outcome."
Carly's mother declined comment. Her daughter, who had suffered through several bouts of tonsillitis, would have been in the seventh grade at Carwise Middle School this year.
"We're very sad for the family. Our hearts go out to them," Hardy said. "We know they are suffering a tragic loss and we understand that."
Pellan said that Carly's brain apparently had some sort of swelling. He also said that many people have some kind of vascular anomaly, but most people don't have any problems with it.
Alec Beningfield, a head and neck surgeon and assistant professor at the University of South Florida, said the problem with the anomaly was one of those one-in-a-million situations.
"It's like getting struck by lightning," he said.
A vascular anomaly, Beningfield said, is an abnormal blood vessel or collection of blood vessels. The most common one that people have heard of is a brain aneurysm, he added. Carly's tonsillectomy procedure was Aug. 13. She went into cardiac arrest during the operation and was transported to All Children's, where she was pronounced brain-dead two days later.
"I feel horrible for the family," Beningfield said. "I also feel horrible for the surgeon and everybody else involved in that case. It's personally and professionally devastating."