Inquest into the death of Anthony Barrett

Contributing factors

• Failure to arrange pre-operative vascular surgeon consultation despite explicit request by orthopaedic surgeon
• Missed opportunities to identify vascular consultation request on admission form across multiple clinical encounters
• Decision to cease clopidogrel (antiplatelet therapy) without vascular specialist input
• Use of tranexamic acid in patient with mesenteric stents at high thrombosis risk
• Lack of familiarity with covered mesenteric stents among non-vascular specialists
• Absence of vascular service at Fairfield Hospital requiring external referral
• Administrative and communication failure in pre-operative clearance process
• Inadequate escalation and consultant review of severe post-operative abdominal pain

Coroner's recommendations

1. Although the coroner determined no formal recommendations were necessary under section 82 of the Act given the substantial systemic improvements already implemented, the South Western Sydney Local Health District had already instituted significant changes including: requiring surgeons to explicitly inform patients that surgery will not proceed without required consultations; flagging specialist clearances on the front of admission forms; automatic referral to cardiology for patients with cardiac history or stents; providing patients with letters specifying required consultations; converting patients to not-ready status until clearances obtained; reminding patients at 3 and 6 months and removing from waiting lists if clearances not obtained; requiring anaesthetist sign-off on medical clearances before surgery scheduling; and documenting these requirements in formal memorandums (30 September 2021 and 7 October 2021)