AN INQUEST INTO THE DEATH OFJOHN BELL
Deceased
John Bell
Demographics
71y, male
Date of death
2014-02-16
Finding date
2018-04-26
Cause of death
cardiac arrest due to hyperkalemia due to acute on chronic renal failure, with recent laparotomy for ileostomy reversal being a significant contributing condition
AI-generated summary
John Bell, a 71-year-old man with history of bowel cancer, ischaemic heart disease, and chronic renal failure, underwent elective ileostomy reversal surgery. He died from cardiac arrest due to hyperkalemia and metabolic acidosis two days post-operatively. Expert renal review identified that his severely impaired kidney function and metabolic acidosis were not adequately investigated or managed preoperatively, and surgery should have been delayed pending renal consultation. Post-operatively, arterial blood gas measurements were not performed to assess acid-base status, and fluid management may have been excessive. While these management gaps may have influenced his clinical course, the expert could not definitively establish they directly caused death, as acute coronary event or occult sepsis could not be excluded. The hospital implemented remedial actions including establishment of a dedicated high-risk pre-admission clinic and improved inter-specialty communication.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- inadequate pre-operative investigation and management of severely impaired kidney function
- inadequate pre-operative management of metabolic acidosis
- failure to obtain renal consultation prior to elective surgery
- inadequate post-operative monitoring of acid-base status
- possible excessive intravenous normal saline administration
- possible occult sepsis
- poor communication between specialties in pre-admission assessment
Coroner's recommendations
- Implementation of dedicated high-risk pre-admission clinic for patients identified by surgeons as requiring that level of service
- Improved inter-specialty communication between surgeons, clinicians, and general practitioners
- Implementation of more efficient lines of communication such as email and online access to patient information
- Broader e-health record system implementation
- Pre-admission redesign project to streamline the pre-admission process and ensure earlier assessment during wait time
- Optimization of patient health prior to elective surgery
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