Dee, Fiona Jane

Contributing factors

• Subdural haematoma secondary to spinal puncture—a rare complication
• Cerebrospinal fluid leak causing post-dural puncture headaches
• Hyponatremia, likely secondary to Tegretol or brain injury
• Failure to arrange clinical review after patient's husband made two telephone calls expressing increasing concern and reporting new vomiting
• Inadequate assessment of deteriorating symptoms by neurosurgeon during telephone consultations
• Lack of multidisciplinary team communication between anaesthetist, obstetrician, and neurosurgeon regarding complex presentation
• No repeat imaging (CT scan) ordered in post-discharge period despite unusual clinical course
• Epileptic seizures despite anti-seizure medication
• Respiratory arrest at time of final collapse causing additional hypoxic injury

Coroner's recommendations

1. Proper review once time has passed to enable impartial, scholarly review of the unusual coalescing conditions in this case
2. Greater knowledge sharing regarding rare complications of spinal anaesthesia and their management
3. Optimisation of holistic team involvement in complex neurosurgical cases requiring multidisciplinary communication between anaesthetists, obstetricians, intensivists, and neurosurgeons
4. Enhanced collegiate discussion and communication between treating specialists in complex cases involving multiple organ systems or unusual presentations
5. Improved documentation of post-operative complications and communication of patient status between different medical teams