Coronial
TAShospital

Coroner's Finding: Nancarrow, Maurice Cecil

Deceased

Maurice Cecil Nancarrow

Demographics

76y, male

Date of death

2015-08-15

Finding date

2017-06-19

Cause of death

multiple organ failure due to large volume aspiration of gastric contents during anaesthetic induction for rigid cystoscopy

AI-generated summary

Maurice Nancarrow, 76, died from multiple organ failure following aspiration of gastric contents during anaesthetic induction for cystoscopy on 15 August 2015. He had undergone colorectal surgery on 30 July with complications including splenic injury. Post-operatively, he developed progressive renal failure, which was misdiagnosed as fluid overload and later attributed to left ureteric obstruction from kidney stone. The coroner found substandard care: failure to investigate renal failure cause, misreporting of CT scan (large bladder and calculus location), missed diagnosis of bladder neck obstruction, and failure to recognize aspiration pneumonia. Had bladder neck obstruction been diagnosed and treated promptly by 10 August, the emergency surgery on 13 August would likely have been avoided, preventing the fatal aspiration event.

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

Specialties

general surgeryurologyintensive careanaesthesiaradiology

Error types

diagnosticcommunication

Drugs involved

diureticscorticosteroidsinotropesantibiotics

Clinical conditions

bladder neck obstructionaspiration pneumoniaacute renal failuresepsisileusbibasal atelectasismyocardial ischaemiahydronephrosisrecurrent diverticulitis

Procedures

Hartmann's procedure with stoma formationreversal of Hartmann's procedurerigid cystoscopydouble J catheter placementmechanical ventilationnaso-gastric tube insertiongastric drainage

Contributing factors

  • failure to investigate progressive renal failure
  • misreporting of CT scan - failure to identify abnormally large bladder
  • misreporting of CT scan - incorrect identification of calculus location in left ureter
  • misdiagnosis of bladder neck obstruction as left ureteric obstruction from calculus
  • failure to diagnose aspiration pneumonia by 13 August
  • inappropriate continued treatment with diuretics for presumed fluid overload
  • unnecessary emergency surgery on 13 August
  • aspiration during anaesthetic induction for cystoscopy

Coroner's recommendations

  1. Implement protocols to ensure investigation of progressive renal failure in post-operative patients
  2. Establish quality assurance processes for radiology reporting to prevent misreporting of CT findings
  3. Develop clinical guidelines for diagnosis and management of bladder outlet obstruction in elderly males
  4. Improve recognition of aspiration pneumonia in post-operative patients with deteriorating respiratory status
  5. Review appropriateness of surgical procedures on critically ill patients with undiagnosed comorbidities
Full text
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