Deceased
Melissa Stokes
Demographics
49y, female
Coroner
Decision ofDeputy State Coroner Truscott
Date of death
2016-08-13
Finding date
2020-11-20
Cause of death
Fatal Cardiac Arrhythmia
AI-generated summary
Melissa Stokes, 49, died from a fatal cardiac arrhythmia one day after successful abdominal hysterectomy and sling surgery. The coroner found the cause was not opioid-induced respiratory depression despite post-operative narcotic use (tramadol, fentanyl). Critical clinical lessons include: nursing observations were inadequately documented and not performed at critical 9pm timepoint; post-operative progress notes were sparse, failing to record nausea/vomiting; fluid intake/output charting was unreliable and retrospectively completed; the patient remained unattended after 10:30pm despite being found with vomitus; and pre-operative respiratory assessment, though appropriate, could have been enhanced given difficult intubation history. The ward was understaffed and busy. The coroner noted that had the cause been opioid toxicity, observant nursing with hourly observations would likely have detected deterioration, but if cardiac arrhythmia (the actual cause), death may have been sudden and silent.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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