Deceased
O
Demographics
82y, male
Coroner
Lock
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. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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