Coroner's Finding: Josipovic, Petar
Deceased
Petar Josipovic
Demographics
62y, male
Date of death
2023-09-14
Finding date
2026-08-13
Cause of death
multi-organ failure on a background of aortic regurgitation and ischaemic heart disease
AI-generated summary
A 62-year-old man with aortic regurgitation and coronary artery disease died from multi-organ failure after emergency cardiothoracic surgery. His elective surgery was cancelled twice (14 and 22 Aug 2023) due to prioritization of urgent inpatient cases with acute coronary syndromes. Critical clinical lessons: when Mr Josipovic reported deterioration on 31 July, this warranted escalation to the surgeon for clinical reassessment, not generic advice to attend ED; had review occurred, rapidly progressive aortic regurgitation would likely have changed surgical priority. He reported further deterioration on 20 August; Dr E. arranged additional capacity but Mr Josipovic did not attend ED as advised. He presented in extremis with cardiac arrest on 24 August. Expert evidence: surgery by 22 August would likely have prevented death (estimated 30% vs 5-8% perioperative mortality), but systemic resource constraints made this impossible. Root causes: limited ICU capacity, inadequate protocols for escalating deteriorating waiting patients, and poor surgeon-patient coordination regarding deterioration.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Delay in performing scheduled cardiothoracic surgery
- Two cancellations due to prioritization of urgent inpatient cases with acute coronary syndromes
- Failure to escalate 31 July patient deterioration report to surgeon for clinical assessment
- Limited intensive care unit bed capacity restricting available surgery slots
- Inadequate protocols for monitoring and responding to deteriorating waiting patients
Coroner's recommendations
- Establish clear guidelines for nursing and administrative staff in each Local Health Network regarding the information and advice to be given to patients awaiting cardiothoracic surgery who report clinical deterioration
- Commission a formal external independent review of cardiothoracic surgical listings practices and procedures to analyse the patient journey and identify risks, including: the referral process and comparison with models such as Monash Health; the capacity of outpatient clinics to provide timely services; costs and benefits of additional theatre lists; financial disincentives for overdue category 1 surgeries; patient swaps between hospitals to distribute urgent case load; shorter-term listings versus long-term scheduling; monitoring systems for patients awaiting surgery and protocols for raising patient concerns with the surgeon; and management of surgical cancellations with clinician involvement
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