Coronial
VIChospital

Finding into death of Penrin John Maxworth Halliday

Deceased

Penrin John Maxworth Halliday

Demographics

60y, male

Date of death

2009-02-02

Finding date

2014-10-02

Cause of death

Ischaemic gut secondary to superior mesenteric artery dissection complicating intra-aortic balloon pump

AI-generated summary

A 60-year-old man with severe coronary artery disease presented with acute myocardial infarction, requiring emergency stenting and subsequent bypass surgery. An intra-aortic balloon pump (IABP) was inserted for haemodynamic support. During IABP removal on post-operative day 1, the patient developed acute abdominal pain with elevated lactate. Imaging revealed superior mesenteric artery dissection with intestinal ischaemia—a recognised but uncommon complication of IABP. Despite emergency surgery and revascularisation, the bowel was profoundly ischaemic and non-viable. The coroner found the recognition of ischaemic gut was timely, surgical referral appropriate, and the IABP use justified given haemodynamic necessity. Key lesson: IABP complications must be recognised quickly; lactate monitoring was appropriately used to identify shock. Surgical delay due to competing emergency transplants was unavoidable but unfortunate.

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

Specialties

cardiologycardiothoracic surgeryvascular surgerygeneral surgeryintensive care

Clinical conditions

acute myocardial infarctioncardiogenic shocksuperior mesenteric artery dissectionischaemic gutmulti-organ failurestent thrombosiscoronary artery stenosishypotension

Procedures

coronary angiographycoronary stent insertionintra-aortic balloon pump insertionintra-aortic balloon pump removalcoronary artery bypass graftingemergency angioplastylaparotomysuperior mesenteric artery embolectomysaphenous vein patch graft to superior mesenteric artery

Contributing factors

  • Superior mesenteric artery dissection as a known complication of IABP insertion/removal
  • Severe underlying coronary artery disease requiring complex cardiac intervention
  • Acute myocardial infarction with cardiogenic shock requiring haemodynamic support
  • Surgical delay due to competing emergency organ transplant cases on 28-29 January
  • Re-infarction requiring repeat angioplasty and subsequent bypass surgery

Coroner's recommendations

  1. The Alfred Hospital's clinical review team should undertake a re-evaluation of staffing levels within the Hospital's Cardiothoracic Unit and determine whether and if so how additional staffing and appropriate clinical support should be provided in circumstances where there are insufficient resources available to undertake an urgent non-elective surgical intervention.
Full text
Official source Archived copy

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 —