Coroner's Finding: PAHL-CADMAN Emma Rose

Contributing factors

• severe cyanotic heart disease with Eisenmenger syndrome and ventricular septal defect
• extremely low preoperative oxygen saturation (48%)
• inadequate anaesthetic risk assessment
• absence of consultant anaesthetist supervision during anaesthesia
• lack of continuous cardiac monitoring post-operatively
• lack of continuous oxygen saturation monitoring post-operatively
• placement on general ward rather than intensive care unit despite critical cardiac condition
• no ECG monitoring post-operatively
• absence of specialist cardiac input prior to surgery
• no use of nitric oxide to reduce pulmonary pressures
• high ventilation pressures during anaesthesia
• postoperative fever with elevated temperature (39.6 degrees) not promptly investigated
• inconsistent oxygen saturation monitoring and recording by nursing staff

Coroner's recommendations

1. Flinders Medical Centre institute a stipulation that no patient with Eisenmenger's Syndrome be anaesthetised except by a Consultant Anaesthetist.
2. Flinders Medical Centre investigate the use of nitric oxide as an ancillary anaesthetic agent in the treatment of such patients.
3. Flinders Medical Centre manage such patients post operatively in the Intensive Care Unit until the Director of ICU certifies that the patient may be moved to the general ward.
4. Flinders Medical Centre require members of its pathology department to certify in their post mortem reports that they have read all relevant hospital notes relating to deceased patients and they have an appreciation of the deceased's underlying medical conditions.