Coroner's Finding: ALLAN Vera

Contributing factors

• Intraoperative haemodynamic instability of uncertain aetiology
• Small left main coronary artery tear (2mm) at ostium
• Change from low-dose adrenaline to noradrenaline by ICU registrar without senior consultation
• Inadequate haemodynamic monitoring in ICU (no Swan-Ganz catheter)
• Lack of senior intensivist presence at handover and delayed involvement in care
• Global myocardial ischaemia secondary to left main coronary stenosis and right coronary artery occlusion
• Prolonged bypass and cross-clamp time during initial surgery and subsequent reoperations
• Lactic acidosis and severe metabolic derangement on ICU admission

Coroner's recommendations

1. ICU staff involved in cardiac surgery post-operative care should attend regular mortality and morbidity meetings held by the Cardiac Unit
2. Cardiac Unit and ICU heads, together with senior management, should address communication issues between the Cardiac Unit and ICU
3. It should be mandatory for ICU staff to confer with members of the surgical team before altering a drug regime chosen by the surgical team that is still being administered at handover to ICU
4. Flinders Medical Centre should review protocols and policies on communication between junior ICU staff and consultant intensivists with the aim of improving patient care and continuity of care
5. Flinders Medical Centre should review protocols and policies on the attendance of consultant intensivists at ICU with a view to requiring a consultant intensivist to attend a patient admitted to ICU in circumstances where they are not otherwise present at handover
6. It should be mandatory for the on-call consultant intensivist to be directly involved in a patient's management plan on admission, whether by telephone or in person, depending upon the complexity and seriousness of the patient's condition upon admission
7. Flinders Medical Centre should review protocols and policies on completing the Death Report to Coroner to ensure that the medical practitioner directly involved in the patient's care completes the deposition
8. Flinders Medical Centre should review protocols and policies on record keeping, particularly in respect of anaesthetic and ICU charts, to minimise ambiguities and handwritten records requiring interpretation, and ensure drugs are recorded clearly with precise dosages and times administered
9. Flinders Medical Centre should review protocols and policies in relation to the use of Swan-Ganz catheters
10. All Flinders Medical Centre ICU staff should receive training on the insertion of Swan-Ganz catheters to ensure patients who require haemodynamic monitoring receive the appropriate level of care
11. The adequacy of Flinders Medical Centre's credentialling of existing doctors and other medical staff should be reviewed and the circumstances surrounding credentialling in late 2009 should be investigated by an appropriate independent authority