Neitsch, Horst - non-inquest findings

Contributing factors

• Iatrogenic left iliac artery perforation during coronary angiography
• Extensive calcified peripheral vascular disease with difficult vascular access
• Inadequate transfer of clinical information and imaging from referring hospital
• Failure to review available prior angiographic and vascular imaging at PAH
• Haemorrhage and hypovolaemic shock from arterial perforation
• Myocardial ischaemia secondary to blood loss in context of severe aortic stenosis and triple vessel coronary disease
• Delayed medical review (9-hour delay) of post-procedure chest pain with acute ECG changes
• Failure to escalate to RRT when patient deteriorated
• Staffing shortages and suboptimal shift handover communication
• Protocol violation - no baseline ECG documented on CCU admission for comparison

Coroner's recommendations

1. Improve documentation and information transfer from referring hospitals to PAH, particularly for complex cases with significant comorbidities
2. Ensure all relevant prior imaging and investigations are reviewed prior to procedures, especially in patients with known vascular disease
3. Develop clear protocols requiring independent assessment and examination of patients by the proceduralist, even if pre-procedure preparation is underway
4. Enhance escalation pathways for post-procedure chest pain with acute ECG changes, with immediate medical review expected within 15-30 minutes rather than hours
5. Reinforce adherence to CCU nursing protocols for management of chest pain and escalation to cardiology registrar on-call
6. Ensure baseline ECG is documented on CCU admission for comparison with subsequent ECGs (protocol compliance)
7. Strengthen training and culture around recognition of deteriorating patients and timely activation of Rapid Response Team
8. Ensure primary responsibility for patient safety is clearly allocated to a senior clinician in complex multi-disciplinary cases
9. Review staffing levels and rostering practices to ensure adequate coverage during sick leave periods, particularly in critical care units
10. Continue education on modern radial access techniques for interventional cardiology procedures to reduce reliance on femoral access in high-risk peripheral vascular disease patients