Inquest into the death of John Gibson
Deceased
John Gibson
Demographics
63y, male
Date of death
2011-07-03
Finding date
2015-03-16
Cause of death
Right cerebral infarction caused by infusion of medication via central venous line inadvertently inserted into the carotid artery
AI-generated summary
A 63-year-old man with COPD, liver cirrhosis and alcohol dependence underwent emergency hemicolectomy for caecal volvulus. Post-operatively he developed respiratory depression, hypernatremia and alcohol withdrawal requiring benzodiazepines and BiPap support. A central venous line was inserted for medication access prior to transfer to ICU. The line was inadvertently placed in the carotid artery rather than jugular vein. Although this was recognised 36 hours later, medications including dextrose had been infused via the arterial line, causing right cerebral infarction. The clinician relied on absence of pulsatile flow and blood colour to confirm placement but failed to perform manometry, transduction, or blood gas assessment despite hypotension making these bedside checks unreliable. Chest X-ray alone cannot confirm venous placement. Best practice mandates formal confirmation of venous placement before use.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Carotid artery misplacement of central venous line
- Failure to confirm venous placement by appropriate bedside checks (manometry, transduction, or blood gas analysis)
- Reliance on unreliable indicators (absence of pulsatile flow and blood colour) when patient was hypotensive
- Absence of formal policy mandating confirmation of venous placement
- Lack of ultrasound-guided placement training for inserting clinician
- Chest X-ray interpretation focused only on tip position, not vessel location
- Delay in recognition of misplacement (36 hours)
- Patient hypotension reducing reliability of pulsatile flow assessment
- Infusion of medications including dextrose via arterial line causing cerebral infarction
Coroner's recommendations
- That the Northern NSW Local Health District introduce a policy mandating that practitioners confirm venous placement of Central Lines consistent with the Medical Quality Committee advice to Grafton Base Hospital on 1 December 2011 and the NSW Health Policy Directive PD2011_060
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