Coroner's Finding: PALTRIDGE Mellanie Joanne

Contributing factors

• failure to diagnose ruptured splenic artery aneurysm prior to catastrophic rupture
• lack of consultant involvement until patient was in extremis
• inadequate knowledge of ruptured splenic artery aneurysm among clinical staff
• planned ultrasound examination not carried out (misplaced request form and lack of clinical urgency)
• false reassurance from period of haemodynamic stability following initial bleed
• focus on alternative diagnoses (renal colic, gallstones) without adequate urgency to exclude life-threatening causes
• cardiac arrest during induction of anaesthesia due to severe hypovolaemia at time of surgery
• delayed diagnosis preventing earlier, less complicated surgical intervention

Coroner's recommendations

1. Educational and professional development strategies be directed to the medical profession, including practitioners and nursing/midwifery staff, concerning ruptured splenic artery aneurysm, specifically addressing: (a) that diagnosis should be considered in any pregnant patient with sudden onset severe left upper-abdominal pain regardless of shock status; (b) symptomatology of the condition; (c) that patients may not present in shock initially; (d) risk of false reassurance from haemodynamic stability; (e) limited reassurance from response to analgesia; (f) diagnostic significance of absence of guarding and rigidity; (g) available diagnostic measures; (h) need for urgency in diagnostic measures when this diagnosis is considered
2. Presentations of pregnant women with sudden onset severe left upper abdominal pain, especially with loss of consciousness, should be immediately referred to a consultant obstetrician/gynaecologist or other consultant-level practitioner
3. Such patients should be subject to continual detailed observation supervised by a consultant-level medical practitioner
4. Endorsement of Victorian Coroner's recommendation that intra-abdominal haemorrhage (e.g. ruptured splenic artery aneurysm, ruptured liver) should be considered in differential diagnosis when pregnant woman presents with severe abdominal pain, especially if requiring narcotic analgesia
5. Consultations between consultant medical practitioners and radiologists regarding appropriateness of CT scans in pregnant women where ruptured splenic artery aneurysm is in differential diagnosis should occur routinely
6. Where ruptured splenic artery aneurysm is in differential diagnosis but other diagnoses need exploration, all diagnostic measures for those other diagnoses should be conducted urgently at first available opportunity
7. Services at Women's and Children's Hospital should be co-located with Royal Adelaide Hospital