Smith, Arthur Lawrence
Deceased
Arthur Lawrence Smith
Demographics
75y, male
Date of death
2004-08-20
Finding date
2007-04-05
Cause of death
Acute cardiac failure due to mitral valve disease (surgically treated)
AI-generated summary
Arthur Lawrence Smith, 75, underwent successful mitral valve repair and coronary artery bypass grafts at TPCH on 2 August 2004 and was discharged 5 days later. On 19 August, his wife called TPCH reporting acute shortness of breath, black motions, and coughing up pink phlegm (pulmonary oedema). Despite his recent cardiac surgery, the triage assessment directed him to RBWH based primarily on gastrointestinal bleeding symptoms, as TPCH lacked gastroenterology services. At RBWH, severe mitral valve regurgitation (4/4) was confirmed with progressive deterioration. After 12 hours, he was transferred to TPCH for emergency mitral valve replacement. Cardiopulmonary bypass could not be weaned; he died from acute cardiac failure. The coroner found the triage assessment inadequate—pulmonary oedema in a post-cardiac surgery patient should have prompted TPCH referral. No evidence suggested earlier admission would have altered outcome. Improvements to triage protocols were noted.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Failure of mitral valve repair—annuloplasty separation and tissue shredding
- Inadequate triage assessment at TPCH leading to misdirection to RBWH
- Insufficient information gathering during telephone triage regarding symptom priority
- Pulmonary oedema misinterpreted relative to gastrointestinal bleeding in clinical context
- Twelve-hour delay before appropriate transfer to TPCH for definitive cardiac surgery
Coroner's recommendations
- Triage assessments should be performed properly with adequate information gathering, particularly assessing the relative urgency and significance of multiple presenting symptoms
- Full-time experienced senior nursing staff should be dedicated to telephone triage assessments
- The significance of pulmonary oedema should be recognised in the context of recent cardiac surgery history
- Clinical history and recent operative status should be weighted appropriately when determining appropriate hospital referral
- TPCH should implement systems to record all triage telephone calls consistently, including those taken by medical staff
- Further implementation of the newly opened general surgery ward at TPCH should be prioritised to eliminate referral delays for conditions such as gastrointestinal bleeding
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