Coronial
NSWhospital

Inquest into the death of Hellen Marsh

Deceased

Hellen Marsh

Demographics

50y, female

Date of death

2013-11-05

Finding date

2016-11-04

Cause of death

Irreversible hypoxic brain injury sustained during surgery for meningioma resection

AI-generated summary

Hellen Marsh, a 50-year-old woman with Fragile X Syndrome and a brain meningioma, died from irreversible hypoxic brain injury sustained during tumour resection surgery. Significant intraoperative blood loss (4,500ml estimated) occurred, with major discrepancies between surgical and anaesthetic team accounts regarding blood salvage device use and monitoring. Critical clinical lessons include: inadequate pre-operative communication between surgeon and anaesthetist regarding tumour vascularity and anticipated bleeding risk; failure to visually monitor all suction containers despite known blood loss concerns; low platelet count (78,000) proceeding to elective brain surgery without consensus on safe thresholds; and incomplete anaesthetic record-keeping. While individual clinical decisions were defensible, systemic communication failures and monitoring gaps were identified. The coroner emphasised that better inter-specialty communication pre- and intra-operatively, enhanced visual monitoring of blood loss across all suction devices, and improved record-keeping would improve future outcomes.

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

Specialties

neurosurgeryanaesthesiaintensive care

Error types

communicationmonitoringsystem

Clinical conditions

meningiomabrain tumourintracranial massthrombocytopeniahypoxic brain injuryhypovolemiaepilepsyfragile x syndromeparoxysmal atrial flutterhypothyroidism

Procedures

meningioma resectioncraniotomydural resectioncell saver blood salvageblood transfusion

Contributing factors

  • Intraoperative hypovolemia and blood loss (4,500ml estimated)
  • Inadequate pre-operative communication between surgical and anaesthetic teams regarding tumour vascularity and anticipated blood loss
  • Failure to monitor blood loss across all suction containers during early surgical phase
  • Low platelet count (78,000) proceeding to elective intracranial surgery
  • Unclear use and monitoring of Cell Saver blood salvage device
  • Incomplete anaesthetic record-keeping
  • Layout of operating theatre obscuring visual access to general suction containers

Coroner's recommendations

  1. That a copy of the coronial findings and reasons, and the transcript of evidence be forwarded to the Chief Executive Officer of the Illawarra Shoalhaven Local Health District with a view to: (a) the findings being used to review the outcomes of the morbidity and mortality meetings (Surgery and ICU) that have taken place to date; and (b) consideration of a joint review between surgery and anaesthetic representatives to discuss expectations around communication between specialities in the lead up to, and during, surgery.
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