Coronial
VIChospital

Finding into death of Lorraine Valerie McDonald

Deceased

LORRAINE VALERIE MCDONALD

Demographics

75y, female

Coroner

Coroner John Olle

Date of death

2008-02-18

Finding date

2011-12-16

Cause of death

hypovolaemic shock from excessive blood loss

AI-generated summary

Lorraine McDonald, age 75, died from hypovolaemic shock due to massive intraoperative bleeding during an anterior resection for rectosigmoid adenocarcinoma. Critical deficiencies included: no pre-admission clinic assessment, no formal preoperative anaesthetic evaluation, failure to perform MRI staging as recommended by radiologist, and failure to recognise the procedure exceeded the rural hospital's capabilities. During surgery, the tumour was found to be more complex than anticipated—adherent to the uterus with a Grade 4 haemorrhage ensuing. The surgeon failed to seek help or 'bail out' early despite losing over 10 litres of blood. The case illustrates failures in preoperative assessment, recognition of case complexity, and intraoperative crisis management. Had appropriate staging been performed, the patient would have been referred to a tertiary hospital with ICU support. The surgeon acknowledged hindsight failings; early transfer with damage control principles might have altered the outcome.

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

Specialties

general surgerycolorectal surgeryanaesthesia

Error types

diagnosticproceduralcommunicationsystemdelay

Clinical conditions

adenocarcinoma of sigmoid colonhypovolaemic shockgrade 4 haemorrhagediverticular disease

Procedures

colonoscopyanterior resectionhysterectomybilateral oophorectomy

Contributing factors

  • inadequate preoperative assessment and staging
  • failure to perform MRI as radiologist recommended
  • failure to refer to colorectal specialist
  • failure to recognise complexity of case before commencing surgery
  • failure to seek expert help or call for assistance intraoperatively
  • failure to implement damage control principles
  • lack of HDU/ICU support at rural hospital
  • inadequate blood products and cross-matching
  • tumour adherence to uterus not anticipated preoperatively
  • surgeon inexperience with massive venous pelvic haemorrhage

Coroner's recommendations

  1. Surgeons must be aware of the nine core competencies and Code of Conduct of the College of Surgeons
  2. Preoperative diagnosis must be confirmed and abnormal radiology findings discussed with radiologists
  3. Surgical units must have weekly meetings with radiologists and pathologists to discuss specific cases
  4. Pre-admission assessment by both anaesthetist and surgical team is paramount
  5. When preoperative assessment highlights potential complexity, surgeons should obtain a second opinion and consider transfer to larger centre
  6. When faced with complex pelvic pathology with potential for bleeding and organ injury, it is preferable to err on the side of caution and not proceed
  7. When encountering catastrophic complications such as haemorrhage, involve the full team including anaesthetist and scrub nurses; always consider calling for expert advice and assistance
  8. Implement damage control principles when encountering complex scenarios—keep the patient alive and address the specific problem on another day
Full text
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Source and disclaimer

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