Coronial
SAhospital

Coroner's Finding: PEDDEY Ross Dudley

Deceased

Ross Dudley Peddey

Demographics

63y, male

Date of death

2001-07-03

Finding date

2004-11-18

Cause of death

pneumonia complicating anoxic brain injury, due to post-operative haemorrhage as a result of damage to the inferior epigastric artery

AI-generated summary

A 63-year-old man died from pneumonia complicating anoxic brain injury following a post-operative haemorrhage from the inferior epigastric artery during ileostomy closure surgery. The critical failure was a 2.5-hour delay (0530-1100 hours) in obtaining intravenous access and blood results that would have revealed a dropped haemoglobin from 130 to 75. Early signs of hypovolaemic shock (hypotension, tachycardia, sweating, dyspnoea) were not recognised as requiring emergency intervention. The junior registrar (Dr T.) inappropriately delegated care to a first-year intern (Dr K.) and left for clinic without follow-up. A CT pulmonary angiogram was pursued despite low clinical probability, delaying diagnosis until cardiac arrest occurred. Earlier recognition of haemorrhage, timely blood investigations, and appropriate escalation would likely have prevented death.

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

Specialties

colorectal surgerygeneral surgeryintensive careanaesthesia

Error types

diagnosticdelaycommunicationsystem

Drugs involved

warfarinheparinfresh frozen plasmahaemaccel

Clinical conditions

post-operative haemorrhagehypovolaemic shockanoxic brain injurycardiac arrestpneumoniadiverticular abscessprosthetic mitral valve

Procedures

sigmoid colectomy with end-to-end anastomosisileostomy closureemergency laparotomycentral venous line insertionCT pulmonary angiogramcardio-pulmonary resuscitation

Contributing factors

  • unrecognised intra-operative damage to inferior epigastric artery during ileostomy closure
  • delayed recognition of post-operative haemorrhage
  • failure to obtain intravenous access in timely manner
  • delayed blood investigation results
  • inappropriate delegation of care to first-year intern without adequate supervision
  • senior registrar (Dr T.) left ward without appropriate follow-up
  • failure to call Medical Emergency Team despite hypotensive shock from 0830 hours
  • diagnostic focus on pulmonary embolism rather than haemorrhage
  • ordering CT pulmonary angiogram with low clinical probability of PE
  • lack of written protocol for registrar supervision and escalation
  • no documentation of Dr K.'s activities and difficulties during the morning

Coroner's recommendations

  1. The Minister of Health and CEO of Flinders Medical Centre should investigate whether Dr K. experienced undue delays in obtaining assistance from the Intensive Care Unit for intravenous access
  2. Investigate why Dr K. experienced delays in obtaining a CT pulmonary angiogram (until 1215 hours)
  3. Investigate any other difficulties junior and middle-ranking medical staff at Flinders Medical Centre experience in obtaining appropriate treatment for patients needing urgent care
  4. Establish protocols for registrar supervision and escalation criteria
  5. Implement procedures to ensure timely escalation to senior staff and urgent medical response teams
Full text
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Source and disclaimer

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