Coronial
QLDhospital

Mr C - Non-inquest findings

Deceased

YC

Demographics

87y, male

Date of death

2015-01-10

Finding date

2017-08-29

Cause of death

Endobronchial and pulmonary haemorrhage secondary to pneumonia complicating chronic anthraco-silicotic lung disease

AI-generated summary

An 87-year-old man with atrial fibrillation on warfarin underwent elective bronchoscopy for suspected lung lesion. The admitting respiratory team incorrectly documented a mechanical aortic valve replacement when he actually had a tissue valve; warfarin was for atrial fibrillation, not the valve. This error led to unnecessary bridging anticoagulation with heparin. The patient developed pulmonary haemorrhage, pneumonia, and respiratory failure post-procedure, dying 2 days after bronchoscopy. Autopsy confirmed haemorrhage as the primary cause. The critical lesson is the importance of accurate identification of prosthetic valve type and correct anticoagulation indication from existing records, as incorrect assumptions can introduce life-threatening bleeding risk during perioperative management.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

respiratory medicinecardiologyanaesthesia

Error types

diagnosticcommunicationsystem

Drugs involved

warfarinheparinaspirinphytomenadioneantibioticsdiuretics

Clinical conditions

atrial fibrillationaortic valve replacementpulmonary haemorrhagepneumoniapulmonary oedemaanthracosilicosiscoronary atherosclerosiscongestive cardiac failureacute kidney injury

Procedures

bronchoscopyendobronchial ultrasound guided biopsybronchial washings and brushingstransbronchial biopsy

Contributing factors

  • Incorrect assumption regarding type of aortic valve replacement (mechanical vs tissue)
  • Failure to review existing medical records documenting valve type and indication for warfarin
  • Unnecessary bridging anticoagulation with heparin due to misidentification of valve type
  • Friable mucosa biopsied during procedure
  • Pneumonia complicating anthraco-silicotic lung disease
  • Patient history transcription error in admission notes

Coroner's recommendations

  1. Implementation of integrated Electronic Medical Records (iEMR) with a common Problem List shared by all clinicians to ensure continuity of understanding of cardiac valve type across treating teams
  2. Use of updated Respiratory Procedure Booking Form with specific documentation of anticoagulation planning and requirements
  3. Enhanced clinician education regarding the distinction between mechanical and bioprosthetic valve replacement and associated anticoagulation indications
  4. Standardised processes to ensure review of previous medical records and imaging when patients are readmitted, particularly for procedural planning
  5. Risk assessment protocols for determining appropriateness of bridging anticoagulation based on current clinical guidelines rather than assumptions
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