Coronial
ACThospital

Inquest into death of JEFFREY BROWN

Deceased

Jeffrey Brown

Demographics

72y, male

Coroner

Coroner Boss

Date of death

2013-04-02

Finding date

2019-11-04

Cause of death

Haemopericardium due to anti-coagulation treatment for pulmonary thromboembolitic disease; fibrinous pericarditis and CABG surgery as significant contributing conditions

AI-generated summary

Jeffrey Brown, a 72-year-old with recent cardiac surgery (CABG), died from haemopericardium due to anticoagulation treatment for pulmonary thromboembolism. Post-mortem examination revealed fibrinous pericarditis (a known post-CABG complication) with acute bleeding into the pericardium causing cardiac tamponade. Although the family raised concerns about delayed diagnoses and missed opportunities to escalate care, independent expert review concluded anticoagulation was medically necessary and appropriate, and that the acute nature of the bleed made earlier diagnosis unlikely. Serial ECGs lacked characteristic tamponade findings. The coroner found no preventable failures in medical management, no matter of public safety, and no adverse findings against treating clinicians.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

cardiothoracic surgerycardiologygeneral medicineintensive careemergency medicine

Drugs involved

warfarinanticoagulants

Clinical conditions

pulmonary thromboembolismmyocardial infarctioncoronary artery diseasefibrinous pericarditispost-cardiac injury syndromecardiac tamponadehaemopericardiumacute kidney injuryliver dysfunctionacute metabolic acidosishyperkalaemiahypoxia

Procedures

carotid endarterectomycoronary angiogramcoronary artery bypass graftresuscitation

Contributing factors

  • Recent coronary artery bypass graft surgery
  • Fibrinous pericarditis (post-cardiac injury syndrome)
  • Anticoagulation therapy for pulmonary thromboembolism
  • Acute pericardial bleeding
  • Underlying liver dysfunction

Coroner's recommendations

  1. Copy of findings and Dr S.'s report to be sent to Pambula District Hospital for information and any appropriate action
  2. Copy of findings and A/Professor Parnia's report to be sent to The Canberra Hospital for information and any appropriate action
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