Cvitic, Nardia Annett

Contributing factors

• Uncontrolled bleeding from lacerated external iliac vein, likely injured by drain trochar insertion on 11 February 2002, tamponaded until drain dislodgement on 14 February 2002
• Failure to perform post-operative haemoglobin testing due to Dr W.'s direction to registrar not to order tests
• Misdiagnosis of pulmonary embolus when clinical presentation was consistent with hypovolaemic shock from blood loss
• Administration of heparin 10,000 units (double standard dose) without empiric confirmation of pulmonary embolus
• Continuation of heparin anticoagulation after cardiologist excluded pulmonary embolus via transoesophageal echocardiography (completed by midday)
• Delayed administration of protamine reversal agent
• Incomplete exploration of abdomen via original transverse surgical incision; only midline incision made at first emergency laparotomy
• Inadequate understanding of bleeding source and blood loss magnitude
• Pre-operative prophylactic Clexane 40 mg (large dose for 52 kg patient) combined with subsequent therapeutic heparin created profound anticoagulation
• Metabolic acidosis and hypovolaemic shock from prolonged hypotension
• Low pre-operative haemoglobin (113 g/L, below normal range 115-165 g/L)
• Fluid and electrolyte imbalances post-operatively without appropriate monitoring

Coroner's recommendations

1. Assiduous record keeping of blood loss and fluid balance from initial surgery through post-operative period and subsequent procedures
2. Routine post-operative blood testing including haemoglobin levels to identify blood loss early, particularly after major surgery
3. Review by relevant colleges of surgery and hospitals of directive protocols to monitor patient condition after major surgery
4. Safe placement protocols for abdominal drains to avoid passage beneath inguinal ligament and vascular injury
5. Review of 'Emergency Surgeon of the Day' role and responsibilities
6. Pathologists performing post-mortems should have attention drawn to specific clinical features requiring verification or elucidation; input from treating team should inform autopsy process
7. Implementation of framework allowing clinicians at any level to report confidential concerns regarding senior colleagues' clinical competence
8. Continued development and awareness of clinical incident reporting systems for sentinel events
9. Greater cooperation and shared resources between hospitals providing gynaecological oncology services
10. Full-time director of gynaecological oncology position should be established to ensure continuity and oversight of complex cases