Coronial
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Finding into death of Sean Raymond Adams

Deceased

Sean Raymond Adams

Demographics

51y, male

Date of death

2012-03-20

Finding date

2013-11-18

Cause of death

Multiorgan failure in a man with corrected congenital coarctation of the aorta and valvular disease

AI-generated summary

Sean Raymond Adams, 51-year-old male with complex cardiac history including corrected coarctation of aorta, valvular disease, and biventricular heart failure, presented to Alfred Hospital ED with chest pain and dyspnoea. He was diagnosed with NSTEMI and admitted. During preparation for cardiac catheterisation, he developed acute deterioration and suffered cardiac arrest. Resuscitation was undertaken following ARC guidelines but was unsuccessful. The coroner found overall clinical management reasonable and appropriate. A key lesson identified was the need for better communication among resuscitation team members and ensuring adequate airway equipment availability on cardiac wards, particularly given documented delays in intubation during the arrest.

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

Specialties

cardiologyemergency medicineanaesthesiapsychiatry

Error types

communicationsystem

Drugs involved

haloperidolmetoclopramideolanzapineparacetamol

Clinical conditions

multi-organ failurebiventricular heart failurenon-st-elevation myocardial infarctioncoarctation of aortamitral valve regurgitationmitral valve repairparoxysmal atrial fibrillationchronic obstructive pulmonary diseaseasthmaacute renal impairmentcardiac arrestpulseless electrical activity

Procedures

cardiac catheterisationangiogramintubationmechanical ventilationcardiopulmonary resuscitationechocardiographyCT pulmonary angiogramCT abdomen and pelvishepatobiliary iminodiacetic acid scanabdominal ultrasound

Contributing factors

  • Severe biventricular heart failure
  • Progressive organ failure
  • Elevated INR at time of planned angiogram
  • Acute renal impairment
  • Deranged liver function
  • Persistent elevated white cell count
  • Delayed intubation due to lack of appropriate airway equipment on ward
  • Poor communication amongst resuscitation team members

Coroner's recommendations

  1. Alfred Hospital staff and management should discuss airway difficulties experienced during the cardiac arrest and address the lack of advanced airway equipment on the ward
  2. Improve communication amongst staff attending cardiac arrests
  3. Ensure adequate airway resuscitation equipment is available on cardiac wards
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