Coronial
NSWhospital

Inquest into the death of Joshua Szczudlo

Deceased

Joshua Tobias Szczudlo

Demographics

33y, male

Date of death

2016-03-19

Finding date

2021-12-02

Cause of death

Fatal cardiac arrhythmia, secondary to acute kidney injury

AI-generated summary

Joshua Szczudlo, a 33-year-old man with morbid obesity (estimated weight 195kg), underwent shoulder fracture repair surgery on 17 March 2016 at Liverpool Hospital. He died 38 hours post-operatively from a fatal cardiac arrhythmia secondary to acute kidney injury with severe hyperkalaemia. Pre-operative assessment identified significant risks (obesity, hypertension, probable sleep apnoea) but surgery proceeded with appropriate anaesthetic management. Post-operative care occurred on a general orthopaedic ward rather than ICU. Key shortcomings included inconsistent supplemental oxygen delivery despite morphine PCA use, and inadequate recording of urine output—both potentially significant in a high-risk patient. While the coroner found no deficiency in care that directly caused death, the case highlights the need for bariatric-specific protocols, reliable weight measurement, and continuous respiratory monitoring for obese post-operative patients on opioids.

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

Specialties

orthopaedic surgeryanaesthesiaintensive carepain medicineemergency medicine

Error types

systemcommunication

Drugs involved

morphineoxycodoneoxycodoneoxycodonemetaraminolparacetamolparecoxib

Clinical conditions

morbid obesityacute kidney injuryhyperkalaemiafatal cardiac arrhythmialeft ventricular hypertrophy and dilationhypertensionobstructive sleep apnoeaupper respiratory tract infectionrhabdomyolysisopioid-induced ventilatory impairment

Procedures

open reduction and internal fixation of shoulder fracturegeneral anaesthesianerve plexus blockendotracheal intubationpatient-controlled analgesia

Contributing factors

  • morbid obesity (super-obese, approximately 195kg)
  • severe acute kidney injury with hyperkalaemia
  • hypertension
  • probable obstructive sleep apnoea
  • recent upper respiratory tract infection
  • post-operative opioid analgesia
  • inadequate supplemental oxygen delivery despite morphine PCA
  • possible rhabdomyolysis from prolonged beach chair positioning
  • possible opioid-induced ventilatory impairment in super-obese patient

Coroner's recommendations

  1. Liverpool Hospital and South Western Sydney Local Health District should review findings regarding inconsistent supplemental oxygen delivery and inadequate urine output recording in high-risk bariatric patients
  2. Ensure accurate weight measurement of all bariatric patients using appropriate bariatric scales throughout the hospital
  3. Develop and implement comprehensive bariatric patient management protocols addressing risks specific to morbid obesity and super-obesity
  4. Consider development of Close Observation Beds (as per NSW Health policy) for post-operative patients with obesity, hypertension, and opioid use requiring continuous respiratory monitoring
  5. Implement continuous respiratory monitoring protocols for obese post-operative patients receiving opioid analgesia, particularly those with risk factors for sleep apnoea
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