Finding into death of William John Colhoun
Deceased
William John Colhoun
Demographics
71y, male
Date of death
2008-12-04
Finding date
2013-08-15
Cause of death
Multi organ failure due to post-operative bleeding following endoluminal thoracic and abdominal aneurysm repair
AI-generated summary
William Colhoun, 71, underwent complex endovascular repair of thoracic-abdominal aortic aneurysm at St Vincent's Private Hospital on 1 December 2008. He developed post-operative instability with hypotension, metabolic acidosis, acute renal failure and coagulopathy. Re-angiography at 10pm on 2 December identified a renal artery tear with active haemorrhage—a previously unreported complication of this procedure. The tear was stented but profound blood loss led to multi-organ failure and death on 4 December. The coroner found clinical management reasonable given the rare complication and confusing clinical picture. However, critical deficiencies were identified in family communication: neither the operating surgeon nor interventional radiologist contacted the family for 30 hours post-operatively, and the surgeon never acknowledged the family during ICU visits. This caused significant unnecessary distress and was deemed unprofessional.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Renal artery tear and dissection from stent placement
- Profound blood loss and haemorrhage
- Complex endovascular procedure with rare complication
- Delayed recognition of bleeding cause due to confusing clinical presentation
- Failure in family communication and support
Coroner's recommendations
- St Vincent's Private Hospital ensure, either by developing and maintaining an education program or some other means, that doctors with admitting rights and hospital medical officers keep family informed of the medical progress and outcomes of patients under their care.
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