Coronial
SAhospital

Coroner's Finding: KRIVITCH Olga

Deceased

Olga Krivitch

Demographics

81y, female

Date of death

2006-01-29

Finding date

2010-02-04

Cause of death

hypovolaemic shock following bleeding from the site of a femoral angiogram

AI-generated summary

Olga Krivitch, 81-year-old woman, died from hypovolaemic shock caused by bleeding from her femoral angiogram puncture site. She was admitted for ischaemic leg and underwent unsuccessful thrombolytic therapy. Subsequently commenced on Heparin anticoagulation but therapeutic range took 38 hours to achieve, exposing her to over-anticoagulation. Critical failures included: haemoglobin levels not monitored on 25-26 January despite evidence of bleeding, resulting in massive undetected haemorrhage; over 4-hour delay between identifying haemoglobin of 54 and transfusion; and lack of experienced senior staff supervision. The Vascular Surgery Unit had no registrars on duty, only junior residents. With timely monitoring, blood transfusion and surgical intervention on 25-26 January, she likely would have survived. Key lessons: mandatory daily haemoglobin monitoring when anticoagulated; explicit instructions to junior staff; adequate senior supervision; Heparin protocols requiring haematology consultation when therapeutic range not established timely.

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

Specialties

vascular surgeryradiologyintensive carehaematologycardiology

Error types

diagnosticmedicationcommunicationsystemdelay

Drugs involved

heparinurokinasewarfarin

Clinical conditions

ischaemic right footacute arterial thrombosis/embolismhypovolaemic shockcoagulopathyover-anticoagulationhaemorrhagerespiratory failurerenal failureischaemic hepatitismetabolic acidosisacute myocardial infarctionatrial fibrillation (suspected)

Procedures

femoral angiographythrombolytic therapyheparin infusionCT scansurgical repair of femoral arteryblood transfusion

Contributing factors

  • over-anticoagulation with heparin
  • delayed establishment of therapeutic anticoagulation range (38 hours)
  • failure to monitor haemoglobin levels on 25 and 26 January 2006 despite evidence of bleeding
  • lack of experienced registrar supervision
  • inadequate staffing in vascular surgery unit
  • delayed identification of haemoglobin level of 54
  • delayed blood transfusion (over 4 hours after critical result identified)
  • delayed surgical repair of bleeding site
  • persistent coagulopathy
  • lack of explicit instructions to junior staff regarding monitoring requirements

Coroner's recommendations

  1. Minister for Health draw findings to attention of all public hospital CEOs regarding need to amend Heparin Protocols based on expert observations, including need to consult haematology if APTT therapeutic range not established timely and need to include protocol copy in patient infusion chart
  2. Minister for Health draw to attention of hospital CEOs the desirability of identifying patient blood grouping in advance of anticoagulation therapy to facilitate timely blood transfusion
  3. Minister for Health draw findings regarding necessity to monitor haemoglobin levels in anticoagulated patients to attention of medical schools in South Australia
  4. Minister for Health take necessary steps to ensure wards in all public hospitals are at all times appropriately staffed
Full text
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Source and disclaimer

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