Deceased
Heather Mary Bird
Demographics
66y, female
Date of death
2014-07-12
Finding date
2017-03-20
Cause of death
retroperitoneal haemorrhage due to anticoagulation following right cerebrovascular infarct following intra-arterial cannulation of the right carotid artery
AI-generated summary
A 66-year-old woman died from retroperitoneal haemorrhage following anticoagulation for stroke caused by intra-arterial central venous catheter placement. The catheter was mistakenly inserted into the right carotid artery instead of the jugular vein. Critical failures included: non-recognition of arterial blood on blood gas analysis (5.02am, 17 June), radiologist's failure to identify malposition on chest X-ray, eight-day delay before catheter removal, and delayed recognition of haemorrhagic shock. When haemoglobin dropped from 138 to 71 g/L, staff dismissed this as 'dilutional' despite anticoagulation therapy, failing to consider retroperitoneal haemorrhage. The MET team lacked appropriate consultant input and delayed diagnosis. A four-hour gap occurred between diagnosis of haemorrhagic shock and ICU review. The coroner found the death almost certainly preventable, highlighting serious deficiencies in MET team consultation and supervision.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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