Inquests into the death of Luke WOOD
Deceased
Luke Wood
Demographics
35y, male
Date of death
2011-08-31
Finding date
2014-11-19
Cause of death
intraperitoneal haemorrhage from an anastomotic leak from a transplanted renal artery
AI-generated summary
Luke Wood, a 35-year-old kidney transplant recipient, died 11 days post-transplant from intraperitoneal haemorrhage due to anastomotic leak from the transplanted renal artery. While post-operative inpatient care and initial post-discharge outpatient monitoring were deemed adequate, the expert assessment identified missed opportunities in the Emergency Department on the day of death. Consultant involvement was delayed for 1.5-2 hours after admission despite the transplant team's availability; no senior consultant personally examined Luke or actively pursued critical CT scan results. Although early senior involvement might not have changed the ultimate outcome, the case highlights the importance of clear command structure, senior clinician engagement from the outset, and timely access to medical records during emergency care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- anastomotic leak from transplanted renal artery
- delayed consultant involvement in emergency department
- lack of clear command structure in emergency care
- delayed access to critical CT scan results
- unavailability of transplant surgical records during emergency surgery
- possible early sign of organ rejection on post-operative day 3
Coroner's recommendations
- Consideration be given to the development of a policy or protocol for the timely provision of all medical records to the coroner when a death is notified pursuant to section 6(1)(b) and (e) of the Coroners Act 2009
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