Coroner's Finding: Dow, Vicki Elizabeth
Deceased
Vicki Elizabeth Dow
Demographics
69y, female
Date of death
2023-06-11
Finding date
2025-04-23
Cause of death
Multiple organ failure due to secondary haemochromatosis (transfusion-associated iron overload) with myelodysplastic syndrome with ringed sideroblasts
AI-generated summary
Mrs Vicki Dow, 69, died from multiple organ failure secondary to iron overload (transfusion-associated haemochromatosis) from treatment of myelodysplastic syndrome. She had declined iron chelation therapy for 19 months despite evidence of iron overload and abnormal echocardiography, deferring treatment to minimise medication burden. By the time chelation commenced in December 2022, transferrin saturation had been at ~100% for years. She subsequently developed iron overload cardiomyopathy, cirrhotic liver changes, and acute renal failure. At emergency admission with perforated gallbladder, liver function tests were not interpreted optimally by surgical teams, though earlier surgery was unlikely to alter outcome given organ damage. Cardiac arrhythmias during surgery lacked clear documentation and early amiodarone treatment. Key lesson: proactive discussion of iron chelation risks versus medication burden is essential; deferral of chelation in transfused patients with documented iron overload represents a missed opportunity for harm prevention.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Deferral of iron chelation therapy for 19 months despite evidence of iron overload
- Patient preference to minimise medication burden delayed chelation commencement
- Prolonged period with transferrin saturation at approximately 100%
- Development of iron overload cardiomyopathy
- Acute perforated gallbladder in setting of iron-damaged liver and compromised cardiac function
- Suboptimal interpretation of liver function tests in emergency department
- Lack of clear delineation and delayed treatment of intraoperative and postoperative cardiac arrhythmias
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