McGuane, Shirley Fay - Non-inquest findings
Deceased
Shirley Fay McGuane
Demographics
84y, female
Date of death
2013-06-28
Finding date
2016-03-18
Cause of death
Myocardial infarction
AI-generated summary
Shirley McGuane, 84, died from myocardial infarction following elective proctocolectomy. Post-operative care was deficient: chest pain on day 2 post-op with ECG showing atrial fibrillation and new right bundle-branch block was not investigated with troponin or blood tests despite this indicating possible myocardial infarction. Significant anaemia (Hb 72, down from 127) and signs of deterioration (oliguria, tachycardia, drowsiness) were not adequately escalated or investigated. No MERT call was made despite meeting criteria. Standard post-operative bloods were not performed. Documentation by the surgeon was minimal despite his shared responsibility for post-operative care. Clinical lessons: post-operative chest pain requires investigation; ECG abnormalities must trigger appropriate escalation and communication; deteriorating patients need formal escalation protocols; and surgeons must document their clinical assessments and decision-making.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to investigate chest pain post-operatively
- failure to perform routine post-operative blood tests
- failure to call MERT despite meeting criteria for rapid atrial fibrillation
- inadequate response to signs of deterioration including oliguria, tachycardia, and altered mental status
- failure to check troponin and cardiac markers despite chest pain and ECG changes
- failure to correct significant anaemia
- inadequate fluid resuscitation for hypovolaemia
- inadequate documentation by surgeon
- unclear ECG review process and lack of communication of ECG findings to treating physicians
- failure to recognize and escalate post-operative myocardial infarction
Coroner's recommendations
- Hospital to continue implementation of Queensland Adult Deterioration Detection System (QADDS) and modified MERT criteria to support timely escalation of deteriorating patients
- Hospital to continue education programs with staff regarding actions required for abnormal ECG results and immediate escalation to treating physicians
- Hospital to recruit additional medical officer for late afternoon and evening ward care to facilitate timely review of test results and clinical assessment
- Hospital to implement daily reporting to Director of Medical Services of reportable deaths and coroner communications
- Strengthen internal death review process (already implemented with addition of Deputy Director of ICU)
- Hospital to confirm clear time and date stamping of ECG reports and ensure ECG reviews are correlated with clinical symptoms and communicated to involved physicians
- Clarify communication pathways for cardiologist ECG reviews to ensure treating physicians are informed of abnormal findings
- Implement process to assist patients, relatives and carers to communicate with health professionals and enable early intervention in deteriorating patients
Full text
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