Coronial
QLDother

Willersdorf, Maria

Deceased

Maria Aurelia Willersdorf

Demographics

87y, female

Coroner

McDougall

Date of death

2015-04-19

Finding date

2020-01-24

Cause of death

Hypoxic-ischaemic encephalopathy secondary to cardiac arrest, with valvular heart disease as antecedent cause. Spinal osteoarthritis (treated) as significant contributing condition.

AI-generated summary

An 87-year-old woman died following a CT-guided epidural injection at a private radiology clinic. Although she had undergone the procedure for spinal pain, the radiologist performed an epidural injection at the T12 level rather than the requested facet joint injections. The patient developed profound hypotension (60/40 mmHg) shortly after the procedure. The treating radiologist failed to recognize the seriousness of her deterioration, provided only minimal fluid resuscitation (50ml saline), left her without adequate supervision, and did not initiate resuscitation despite her showing signs of agonal breathing. She suffered cardiac arrest before ambulance arrival. Expert evidence indicated that aggressive fluid and vasopressor therapy would have had a 90% chance of preventing the cardiac arrest. The death highlights critical failures in post-procedure monitoring, recognition of medical emergencies, and inadequate emergency equipment and staffing at a private radiology practice.

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

Specialties

radiologypain medicineanaesthesiaemergency medicinegeneral practice

Error types

diagnosticproceduralcommunicationsystemdelay

Drugs involved

bupivacainelidocainecelestone chondronoseadrenaline

Clinical conditions

hypotensioncardiac arrestvalvular heart diseasespinal osteoarthritisosteoporosisrheumatoid arthritisagonal breathinghypoxic ischaemic encephalopathy

Procedures

ct-guided epidural injection

Contributing factors

  • epidural injection at T12 level causing hypotension
  • profound hypotension (60/40 mmHg)
  • failure to recognize serious deterioration
  • inadequate fluid resuscitation (50ml saline only)
  • failure to provide adequate post-procedure monitoring
  • failure to initiate timely resuscitation
  • insufficient emergency equipment
  • lack of nursing support
  • radiologist left patient unattended despite medical emergency
  • underlying unrecognized valvular heart disease

Coroner's recommendations

  1. Royal Australian and New Zealand College of Radiologists to amend Standards of Practice within 12 months to require electrocardiography monitoring for spinal tap, epidural and spinal nerve root block procedures where patients have risk factors (age, frailty, comorbidities)
  2. RANZCR to amend Radiodiagnosis Curriculum within 12 months to require radiologists performing contrast and sedation to hold CPR certification for advanced life support
  3. IRIS Imaging to implement all recommendations from independent IRIS Imaging Review within 6 months and engage independent reviewer for further assessment within 12 months
  4. IRIS Imaging to continue thorough patient assessments identifying comorbidities and refer patients with increased risk to emergency department
  5. IRIS Imaging not perform Type A interventional procedures (spinal tap, epidural, spinal nerve root block) unless: (a) Dr E. completes RANZCR Advanced Life Support and CPR Workshop within 12 months and undertakes annual refresher courses; (b) participates in RANZCR CPD program annually; (c) a nurse is present at all times during procedures and recovery; (d) ECG machines are purchased and utilized in recovery room; (e) all intervention procedure patients remain for 60 minutes with pulse oximetry and ECG monitoring; (f) nurse conducts regular checks and stock audits of resuscitation drugs; (g) defibrillator trolley is located in designated recovery room
Full text
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