Deceased
Tama Galiere
Demographics
0y, unknown
Coroner
Decision ofDeputy State Coroner Dillon
Date of death
2008-06-25
Finding date
2014-05-09
Cause of death
focal ventricular myocarditis and myonecrosis resulting from migration of a Peripherally Inserted Central Catheter (PICC line) into the right ventricle
AI-generated summary
A 10-month-old boy died from myocarditis and myonecrosis caused by migration of a PICC line into his right ventricle. The line was inserted appropriately under general anaesthetic for IV antibiotics treating periorbital cellulitis. Initial placement in the right atrium was confirmed on post-insertion X-ray. However, the PICC line subsequently migrated into the right ventricle, likely after the securing dressing was changed by ward staff. Clinical lessons include: securing PICC lines requires careful attention to maintenance of dressings and documentation of any dressing changes; daily surveillance for line migration is essential; using image intensification during insertion reduces risk; and consideration of suturing in specific contexts. The hospital implemented comprehensive improvements including daily PICC line checks by specialist nurses, continuous image intensification during placement, and enhanced protocols for PICC management.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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