Mr DAC - Non-inquest findings
Deceased
DAC
Demographics
51y, male
Date of death
2017-06-26
Finding date
2019-09-03
Cause of death
Sepsis due to or as a consequence of right lower limb necrotising fasciitis due to or as a consequence of right inguinal femoral artery pseudo-aneurysm, coronary atherosclerosis (stent insertion), and ischaemic heart disease
AI-generated summary
A 51-year-old man with metastatic renal cell carcinoma died from sepsis following necrotising fasciitis of the lower limb, which developed after a pseudo-aneurysm complication from coronary angiography. Key clinical lessons: (1) inadequate pre-procedure assessment in a complex patient with multiple comorbidities and anticoagulation; (2) failure to recognise and act on post-procedure bleeding complications—a competent cardiologist should have performed urgent ultrasound imaging on 11 May to exclude pseudo-aneurysm, which could have been treated with thrombin injection; (3) lack of communication between teams regarding palliative status and prognosis; (4) selection of femoral rather than radial approach despite obesity and bleeding risk. The post-operative bleeding management was deemed negligent and below standard of care. Early diagnosis and thrombin injection would almost certainly have prevented the catastrophic outcome.
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 perform pre-procedure evaluation prior to angiography
- Selection of femoral arterial approach despite high bleeding risk (obesity, anticoagulation)
- Inadequate post-procedure monitoring and assessment of bleeding complications
- Failure to perform urgent ultrasound imaging to diagnose pseudo-aneurysm on 11 May 2017
- Delayed diagnosis of pseudo-aneurysm
- Metastatic malignancy with immune suppression from chemotherapy (Pazopanib)
- Long-term steroid use impairing wound healing and immune response
- Triple anticoagulation therapy (Aspirin, Clopidogrel, Rivaroxaban)
- Lack of communication between cardiology and palliative care teams regarding prognosis
- Obesity (BMI > 36) complicating haemostasis
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