Coronial
VIChospital

Finding into death of Bruce John Stubbs

Deceased

BRUCE JOHN STUBBS

Demographics

59y, male

Coroner

Coroner Peter White

Date of death

2008-04-23

Finding date

2013-04-12

Cause of death

Ruptured atherosclerotic abdominal aortic aneurysm (operated)

AI-generated summary

A 59-year-old man with a non-ruptured 8cm infrarenal abdominal aortic aneurysm (AAA) presenting with acute back pain was transferred from Bendigo to Royal Melbourne Hospital at 2.13am on 22 April 2008. Despite appropriate initial assessment identifying the AAA as requiring urgent repair, surgical staff deferred surgery twice—once at 3.20am and again at noon—delaying intervention for 34 hours. The patient was haemodynamically stable initially, but had ongoing pain managed with intravenous morphine. The coroner found that use of analgesia likely masked the clinical urgency and contributed to delay. The aneurysm ruptured overnight on 22-23 April. Emergency surgery on 23 April revealed rupture and perioperative complications led to cardiac arrest and death. The coroner found the surgical delays suboptimal; had surgery occurred promptly on admission, survival probability exceeded 80%. Key lessons: symptomatic large AAA with pain requires urgent same-day surgery; analgesia can be misleading; delays in high-risk presentations carry critical consequences.

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

Specialties

vascular surgeryemergency medicineanaesthesia

Error types

diagnosticdelaycommunication

Drugs involved

morphineoxycodone

Clinical conditions

abdominal aortic aneurysmruptured aortic aneurysmaortic ruptureback painhypercholesterolaemiahypertensiondehydration

Procedures

CT scan (abdominal)open operative repairaortic tube graftemergency re-exploration

Contributing factors

  • Delayed surgical intervention despite symptomatic large AAA
  • Intravenous morphine masking clinical urgency
  • Haemodynamic stability misleading clinical assessment
  • First deferral of surgery at 3.20am by telephone consultation
  • Second deferral of surgery at noon, rescheduled for 48 hours later
  • Failure to recognise that ongoing pain despite analgesia signalled urgency
  • Night resident (Dr Liava'a) not appropriately escalating drop in blood pressure to on-call senior registrar
  • Rupture occurring overnight 22-23 April during extended interval before scheduled surgery

Coroner's recommendations

  1. In cases of symptomatic large AAA causing pain, immediate surgical intervention should be the paramount consideration and should dominate discussion on management
  2. A symptomatic AAA with ongoing pain requiring analgesics is a clear signal for urgent surgery as soon as possible, typically performed the same day
  3. Morphine and other analgesics used for symptomatic AAA can mask the clinical urgency and mislead staff into underestimating the need for prompt surgical intervention
  4. Staff must recognise that haemodynamic stability does not preclude urgent surgical need in symptomatic AAA
  5. The Deteriorating Patient Project developed at RMH following internal investigation is endorsed and appears to be an excellent initiative for early identification
Full text
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Source and disclaimer

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