Finding into death of Michelle Johnson
Deceased
Michelle Johnson
Demographics
31y, female
Date of death
2010-03-22
Finding date
2014-03-21
Cause of death
Ruptured splenic artery aneurysm with extensive retroperitoneal and intraperitoneal haemorrhage
AI-generated summary
Michelle Johnson, a 31-year-old pregnant woman at 32 weeks gestation, presented to the Royal Women's Hospital with sudden-onset severe left-sided abdominal pain and hypotension on 21 March 2010. She was assessed by registrar Dr F. and covering specialist Dr L., with initial low blood pressure attributed to musculoskeletal pain from dancing. Investigations were unremarkable. After discharge that evening, she collapsed the following morning and was found to have a ruptured splenic artery aneurysm, a rare but recognised pregnancy complication. The coroner found her initial assessment was appropriate and no failure to diagnose represents medical deficiency, given the condition's extreme rarity. However, communication breakdowns occurred between hospital staff and the private obstetrician. The key clinical lesson is that intra-abdominal haemorrhage must be considered in differential diagnosis when pregnant women present with severe abdominal pain requiring narcotic analgesia.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Rare splenic artery aneurysm associated with pregnancy
- Initial presentation symptoms (abdominal pain, hypotension) were premonitory/leak phase, with subsequent acute rupture 20-30 hours later
- Communication breakdown between hospital registrar and covering obstetrician
- Failure of covering obstetrician to review patient on ward as planned
- Patient discharged before being reviewed by covering specialist
Coroner's recommendations
- Intra-abdominal haemorrhage (e.g. ruptured splenic artery aneurysm, ruptured liver) should be considered as part of the differential diagnosis when a pregnant woman presents with severe abdominal pain especially if she requires narcotic analgesia
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