Finding into death of Kum Yeo Bae
Deceased
Kum Yeo Bae
Demographics
60y, female
Date of death
2005-03-21
Finding date
2010-04-16
Cause of death
Penetrating injury of the descending thoracic aorta complicating spinal stabilization surgery for a T12 burst fracture
AI-generated summary
A 60-year-old woman died from a penetrating injury to the descending thoracic aorta sustained during spinal stabilisation surgery for a T12 burst fracture. During pedicle cannulation, the surgical awl fractured the left T11 pedicle and plunged superiorly, causing acute blood loss of 300-400ml and aortic laceration. Critical communication failure occurred: the surgeon believed blood loss was minimal, the anaesthetist understood it occurred over the entire procedure rather than acutely, and the senior surgeon was not informed of the acute loss. Haemodynamic stability was rapidly achieved with fluids, masking the severity of injury. The coroner found the decision to proceed with surgery was reasonable and the death was not preventable. Key learning: acute blood loss of this magnitude in this context warrants immediate senior consultation and consideration of thoracic surgical involvement.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Pedicle awl plunged during cannulation of left T11 pedicle
- Acute blood loss of 300-400ml not immediately recognized as acute episode
- Communication failure between operating team and senior surgeon
- Surgeon believed blood loss was minor
- Anaesthetist misunderstood timing of blood loss
- Haemodynamic stability achieved with fluids, masking severity of injury
- Senior surgeon not fully informed of acute blood loss episode
- Absence of intraoperative CT angiogram suite
- Delayed recognition of aortic injury
Coroner's recommendations
- The Alfred Hospital consider the construction of intraoperative CT scan suites
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —