Coronial
NSWhospital

Inquest into the death of Heather Winchester

Deceased

Heather Winchester

Demographics

75y, female

Coroner

Decision ofDeputy State Coroner O'Neil

Date of death

2019-09-27

Finding date

2025-02-28

Cause of death

multiple organ failure due to severe anaemia secondary to blood loss post elective hysterectomy surgery, with contributing factors being ischaemic heart disease, chronic kidney injury, and diabetes

AI-generated summary

A 75-year-old woman died from multiple organ failure due to severe anaemia after elective hysterectomy surgery. Critical failures occurred: the surgical and anaesthetic teams held conflicting understandings about whether she would accept blood transfusion—the surgeon believed she refused all blood products based on her consent form and Jehovah's Witness faith, while the anaesthetist believed she accepted packed red blood cells based on worksheets presented during pre-operative assessment. These differing understandings were not identified before surgery or during the timeout procedure. When massive post-operative bleeding occurred, the patient ultimately refused transfusion and died. Clinicians should ensure all team members review pre-anaesthetic clinic notes before surgery, clarify blood product refusal through structured procedures, implement robust timeout protocols to identify inconsistencies, and recognise that religious documents may be confusing and require explicit clinical discussion.

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

Specialties

gynaecologyanaesthesiaintensive carecardiology

Error types

communicationsystemdiagnostic

Clinical conditions

hysterectomy-related complicationspelvic haematomaarterial haemorrhagesevere anaemiaischaemic heart diseasechronic kidney injurytype 2 diabetesmultiple organ failure

Procedures

hysterectomyCT imaginglaparotomyabdominal packing

Contributing factors

  • differing understandings between surgical and anaesthetic teams regarding blood product acceptance
  • failure to review consent form during pre-operative assessment
  • inadequate risk counselling regarding patient comorbidities
  • failure to identify inconsistencies during timeout procedure
  • confusing religious documentation (Worksheets 1 and 2)
  • poor coordination between surgical and anaesthetic teams
  • uncertainty regarding aspirin use
  • inadequate systems for identifying treatment refusals

Coroner's recommendations

  1. Hunter New England Local Health District must put in place a requirement that a member of the surgical team review the pre-anaesthetic clinic notes prior to surgery
  2. Review the timeout procedure in the Clinical Procedure Safety policy to identify anomalies such as blood screening conducted for patients who have refused transfusion
  3. Implement a procedure followed by all relevant medical staff when a patient identifies as a Jehovah's Witness, including: advising of Jehovah's Witness Hospital Liaison Committee availability; providing an appropriate form for partial refusal of blood products; providing a checklist of available blood products; listing all documentation to be sought from the patient
  4. The Chief Executive at Hunter New England Local Health District take steps to resume regular meetings between the church's Hospital Liaison Committee and Directors of Medical Services at each hospital to enhance understanding of Jehovah's Witness treatment preferences and available resources
  5. Training and education provided to visiting medical officers and locums be reviewed to ensure they understand how to access all relevant electronic records and their responsibility to do so
  6. All New South Wales congregants of Jehovah's Witnesses be advised that Worksheets 1 and 2 are no longer to be relied upon and should not be used for any purpose; this advice should be conveyed through all available resources
  7. The church advise congregants in New South Wales of the precise status of development of products from human or animal haemoglobin for treating acute anaemia or massive blood loss; advice should be relayed through all available resources
Full text
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