Non-inquest findings into the death of Mr C

Contributing factors

• Diagnostic discrepancy: preoperative biopsy diagnosed benign anastomosing haemangioma but autopsy revealed metastatic clear cell renal cell carcinoma
• Inoperable tumour with extensive invasion into liver, retroperitoneum, adrenal gland, diaphragm and abutting inferior vena cava
• Uncontrolled venous back-bleeding from liver edge
• Late recognition and quantification of massive blood loss
• Delayed activation of massive transfusion protocol
• Loss of central venous line preventing inotrope administration and contributing to refractory hypotension
• Suboptimal fluid resuscitation between 3:30 and 5:00pm
• Poor communication between surgical and anaesthetic teams
• Inexperienced team composition for complex case
• Case scheduled for afternoon slot rather than morning, limiting available resources and staffing
• Anaesthetist not routinely working with this surgical team
• Preoperative hypotension despite metaraminol treatment
• Issues with cell saver use and contamination with haemostatic agent
• Inadequate monitoring of central venous pressure

Coroner's recommendations

1. Visiting medical practitioners to discuss complexity of cases with theatre manager when cases may not complete within allocated session time
2. Review organisation's procedures for documentation of CVL placement and confirmation of correct positioning at insertion, possibly including a checklist
3. Review anaesthetic staff roles and responsibilities regarding documentation of fluid administered and overall blood loss intraoperatively
4. Review education and training for anaesthetic staff regarding documentation and communication of estimated blood loss and escalation procedures
5. Review and amend intraoperative cell salvage procedure to clarify responsibility between surgeon and anaesthetist, include troubleshooting for haemostatic agent complications, and guidance on abandonment
6. Review education and training for anaesthetic assistants and theatre nursing staff regarding cell salvage use and troubleshooting
7. Chief Medical Officer to communicate with all anaesthetic and surgical visiting medical practitioners regarding cell salvage responsibility and abandonment criteria
8. Review location and availability of emergency cell salvage equipment
9. Review and amend hospital massive transfusion protocol to clearly capture activation triggers, align with National Blood Authority major haemorrhage protocol, and include instructions on delivery, storage and handling of blood products
10. Develop massive transfusion protocol education including simulation training with procedural teams covering clear communication of activation and appropriate replacement ratios
11. Review escalation process and triggers for activation of theatre emergency buzzer
12. Consider publication of case report to educate clinicians about rare presentation of anastomosing haemangioma with metastatic clear cell renal cell carcinoma