Woolgar, Shealah Ann
Deceased
Shealah Ann Woolgar
Demographics
83y, female
Date of death
2007-08-22
Finding date
2009-03-20
Cause of death
Haemorrhage due to mitral valve disease (surgically repaired); specifically haemorrhage from a left ventricular perforation sustained during intra-operative valve testing
AI-generated summary
An 83-year-old woman died from haemorrhage following mitral and tricuspid valve repair surgery. During intra-operative testing of the repaired mitral valve using Blake's tubing (soft rubber tubing with a bevelled end) attached to a syringe, the tubing perforated the left ventricle. The perforation initially appeared small but extended when the heart was placed under pressure after cardiopulmonary bypass was discontinued. Dr T.'s attempts to repair the perforation were unsuccessful, resulting in fatal bleeding. The coroner found the perforation was caused by insertion of the bevelled-end tubing too far into the ventricle, contacting the weakened left ventricular wall. Key clinical lessons include: the importance of minimal insertion depth when testing valve competency; avoiding bevelled tubing ends; recognition that soft rubber instruments can cause significant myocardial trauma if advanced excessively; and careful attention to equipment preparation. The coroner declined to refer Dr T. to the Medical Board, noting this was unusual trauma occurring during appropriate surgery.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Insertion of bevelled-end Blake's tubing too far into left ventricle during valve competency testing
- Use of bevelled rather than blunt-cut tubing end
- Thin, weakened ventricular wall secondary to congestive heart failure
- Inadequate visual inspection of tubing end by surgeon
- Extension of initial partial perforation when heart placed under pressure post-bypass
- Unsuccessful repair attempts due to friable tissue and continued bleeding
Coroner's recommendations
- Copy of findings to be sent to Royal Australasian College of Surgeons for use in clinical education and advancement of cardiac surgical technique
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