Coronial
QLDhospital

Rawson, Robert Donald

Deceased

Robert Donald Rawson

Demographics

68y, male

Coroner

Hennessy

Date of death

2004-11-24

Finding date

2006-09-13

Cause of death

Internal haemorrhage due to coagulopathy and upper gastrointestinal varices, cirrhosis of the liver, alcohol consumption, and recent myocardial infarction

AI-generated summary

Robert Donald Rawson, a 68-year-old man with end-stage cirrhosis and multiple comorbidities, died hours after undergoing intercostal catheter insertion for pleural effusion drainage at Rockhampton Hospital. While the procedure itself was clinically appropriate and supported by tertiary referral, the coroner found systemic issues in regional practice: the procedure was conducted in a ward rather than a sterile theatre, performed by an inexperienced practitioner, involved ill-fitting equipment requiring adaptation, and had inadequate documentation and family communication. Expert evidence concluded the procedure unlikely contributed significantly to death, which resulted from rapid hepatic decompensation, coagulopathy, gastrointestinal bleeding, and acute cardiac events. The coroner recommended Queensland Health address equipment standardisation, staff training in surgical skills, procedural venue standards, and documentation practices in regional centres.

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

Specialties

general surgeryrespiratory medicinegastroenterologytransplant medicineemergency medicine

Error types

systemproceduralcommunication

Drugs involved

fresh frozen plasma

Clinical conditions

cirrhosis of the liverend-stage liver diseasepleural effusioncoagulopathyupper gastrointestinal varicesgastrointestinal haemorrhagemyocardial infarctionsepsis riskcardiac arrhythmia

Procedures

intercostal catheter insertionpleural effusion drainage

Contributing factors

  • end-stage liver disease with rapidly declining liver function
  • coagulopathy
  • gastrointestinal bleeding
  • recent myocardial infarction
  • plural effusion requiring drainage
  • possible minor arterial bleeding at catheter insertion site
  • regional hospital resource and capability limitations

Coroner's recommendations

  1. Queensland Health should standardise practices and preparation of equipment for procedures in regional centres to match major public hospitals
  2. Improve communication with patients and families regarding medical procedures such as intercostal catheter insertion, including appropriate written consent documentation
  3. Improve documentation relating to medical procedures and ensure appropriate and timely documentation of medical chart records
  4. Ensure intercostal catheter insertion procedures are conducted in appropriately equipped rooms (sterile procedure room or theatre) rather than ward settings
  5. Implement comprehensive clinical training in surgical skills for medical and nursing personnel, particularly in regional hospitals, and ensure uptake of available training
  6. Address difficulties in maintaining supplies of standard equipment sets to regional centres
Full text
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