Coroner's Finding: Hargraves, Audrey Doreen
Deceased
Audrey Doreen Hargraves
Demographics
80y, female
Date of death
2018-08-31
Finding date
2020-04-03
Cause of death
sudden cardiac arrest due to multiple post-operative complications including myocardial ischaemia, ischaemic enteritis, and lobar pneumonia following reversal of Hartmann's procedure and extensive adhesiolysis
AI-generated summary
An 80-year-old woman died from multiple post-operative complications following reversal of a Hartmann's procedure for diverticulitis. She had undergone a complex 8-hour surgery complicated by extensive adhesions (frozen pelvis). Post-operatively, she developed ileus and was transferred to a tertiary hospital for TPN and bowel stimulation. She had an undiagnosed long QT syndrome (identified on a 2010 ECG). At the receiving hospital, she was administered multiple QT-prolonging drugs (erythromycin and metoclopramide) without obtaining or reviewing her ECG, contributing to fatal cardiac arrhythmia. The coroner found her death was multifactorial but recommended that ECGs be performed before initiating QT-prolonging drugs in multiple combinations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- long QT syndrome exacerbated by QT-prolonging drugs (erythromycin and metoclopramide)
- pre-existing coronary artery disease with myocardial ischaemia
- prolonged and difficult surgery lasting 8 hours
- frozen pelvis with extensive adhesions
- post-operative ileus
- slow recovery and deconditioning
- decreased nutritional state
- failure to screen with ECG before administering multiple QT-prolonging drugs
Coroner's recommendations
- Hospital medical staff should perform an electrocardiogram (ECG) as a screening test before patients are placed on multiple QT prolongation treatments
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