SWK - Non inquest findings
Deceased
Ms SWK
Demographics
78y, female
Date of death
2011-03-30
Finding date
2017-10-17
Cause of death
multi-organ failure due to haemorrhage into the abdomen, pelvis and retroperitoneum following lumbosacral spinal surgery; refusal of blood transfusion was a significant contributing condition
AI-generated summary
78-year-old Jehovah's Witness died from multi-organ failure secondary to intra-abdominal and retroperitoneal haemorrhage following extensive anterior and posterior lumbar spinal fusion surgery. The patient had multiple comorbidities, previous spinal surgery with persistent pain, osteoporosis, and religious refusal of blood transfusion. During surgery, she became hypotensive and tachycardic during the posterior approach but surgery continued without re-exploration of the anterior site. Post-operative imaging failed to identify the bleeding source, though autopsy revealed significant haemorrhage. Expert reviewers disagreed on whether the surgery was justified: one neurosurgeon considered it clinically unwise given age, comorbidities, and refusal of transfusion, while a spinal surgeon deemed it technically reasonable given Dr M's extensive experience and thorough informed consent. Key learning: extreme caution required before major elective spinal surgery in elderly patients with multiple comorbidities and religious contraindications to blood products; intraoperative haemodynamic deterioration warrants prompt re-exploration when alternative causes excluded.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- haemorrhage from retroperitoneal/abdominal bleeding source not identified intraoperatively
- refusal of blood transfusion due to Jehovah's Witness religious beliefs
- failure to re-explore anterior surgical site when patient became hypotensive during posterior approach
- post-operative imaging failed to identify exact bleeding source
- extensive complex spinal surgery in elderly patient with multiple comorbidities
- osteoporosis
- previous spinal surgery with poor outcome
Coroner's recommendations
- The decision to undertake major elective spinal surgery in elderly patients with multiple comorbidities and religious refusal of blood transfusion should involve careful consideration of whether the level of risk is justified by expected benefit
- Intraoperative haemodynamic deterioration in major spinal surgery warrants prompt investigation and potential re-exploration of the surgical field when alternative explanations have been excluded
- Informed consent processes for spinal surgery in patients with blood transfusion refusal should explicitly document discussions about the specific risks of haemorrhage and unavailability of this life-saving intervention
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —