O - Non-inquest findings
Deceased
O
Demographics
82y, male
Date of death
2011-05-16
Finding date
2014-06-20
Cause of death
hypoxic-ischaemic encephalopathy due to cardiac arrest as a result of fractured right fibula (surgically treated)
AI-generated summary
An 82-year-old man died from hypoxic-ischaemic encephalopathy following perioperative cardiac arrest during ankle fracture surgery. The anesthetist failed to recognise clinical deterioration, did not intubate despite signs of hypoxia and hypotension, and allegedly prevented nursing staff from calling for emergency assistance. The pre-operative assessment was incomplete, lacking airway assessment and risk stratification despite known cardiac issues including atrial fibrillation. Expert review found the anesthetist should have obtained assistance earlier and been more proactive in managing developing hypotension and hypoxia. AHPRA found unsatisfactory professional performance. Clinical lessons include: complete pre-operative cardiac assessment in elderly patients with arrhythmias; recognise and escalate perioperative deterioration promptly; never obstruct emergency communication; and seek timely assistance during crises.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to recognise vital sign deterioration requiring emergency intervention
- failure to intubate to ensure adequate ventilation
- failure to obtain timely assistance during clinical deterioration
- obstruction of emergency communication
- incomplete pre-operative assessment
- underlying cardiomyopathy and coronary artery disease
- pulmonary embolism and deep vein thrombosis
- atrial fibrillation
Coroner's recommendations
- Complete pre-operative anaesthetic assessment including airway assessment, neck movement assessment, and risk stratification prior to all operative procedures
- Mandatory escalation and assistance-seeking protocols during perioperative crises
- Enhanced recognition and management of perioperative complications in elderly patients with significant cardiac disease
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