Coronial
QLDhospital

Smith, Darryl Robert

Deceased

Darryl Robert Smith

Demographics

34y, male

Coroner

Lock

Date of death

2009-06-11

Finding date

2011-11-04

Cause of death

Air embolism and severe haemorrhage due to perforation of the right subclavian vein during surgery for the repair of a fractured right clavicle due to a fall

AI-generated summary

Darryl Smith, aged 34, died following emergency surgery for a fractured clavicle at Sunnybank Private Hospital. During the final drilling of the sixth screw hole, the surgeon's drill penetrated the underlying right subclavian vein, causing massive haemorrhage. Despite aggressive resuscitation including blood products, intubation, and CPR, the patient deteriorated and an air embolism was eventually diagnosed post-mortem. The coroner found the surgeon used standard surgical technique and appropriate equipment, but the drill advanced deeper than expected, breaching the vein. Complications from the haemorrhage and subsequent air embolism proved fatal. The coroner found no disciplinary issues but recommended the case be referred to surgical colleges for education, and to equipment manufacturers to explore future drill stop technology to prevent similar vascular perforations during orthopaedic procedures.

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

Specialties

orthopaedic surgeryanaesthesiavascular surgerygeneral surgery

Error types

proceduraldelay

Drugs involved

adrenalineatropinegelofusinehartmansalbumexsodium bicarbonate

Clinical conditions

clavicle fracturesubclavian vein perforationhaemorrhagehypovolaemiaair embolismpneumothoraxcardiac arrestshock

Procedures

open reduction and internal fixation of clavicle fractureclavicle locking plate insertiondrilling of screw holesintubationcardiopulmonary resuscitationchest drain insertioncentral venous line insertionfemoral infusiondefibrillation

Contributing factors

  • Perforation of right subclavian vein during drill insertion for sixth screw hole
  • Excessive drill penetration depth or trajectory
  • Late diagnosis of air embolism during resuscitation
  • Possible failure of Bristow elevator to prevent drill advancing into soft tissue
  • Extensive blood loss from subclavian vein puncture
  • Combination of hypovolaemia and air embolism as causes of cardiac arrest

Coroner's recommendations

  1. Refer the case to the Royal College of Surgeons, the Royal College of Anaesthetists of Australia and New Zealand, and the Shoulder and Elbow Society of Australia as a case study for discussion and learning amongst members
  2. Request Synthes Australia and Smith & Nephew Surgical to refer the case to their research and development departments to assist in informing future design choices for drill bits, particularly regarding commercial and technical feasibility of drill stops for orthopaedic surgery
  3. Review and strengthen hospital policies and procedures for trialling new surgical equipment to ensure adequate training and presence of equipment representatives
  4. Consideration by hospitals and surgical teams of positive ventilation protocols similar to those used in neurosurgery to help prevent air embolism complications
  5. Increased awareness among anaesthetists that air embolism can occur as a complication in orthopaedic surgery, not just neurosurgery and vascular surgery
Full text
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Source and disclaimer

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