Coronial
VIChospital

Finding into death of Kelly Maree Richards

Deceased

Kelly Maree Richards

Demographics

29y, female

Coroner

Deputy State Coroner Iain West

Date of death

2011-07-13

Finding date

2016-04-14

Cause of death

Exsanguination post tubal ligation procedure

AI-generated summary

A 29-year-old woman died from exsanguination following an iatrogenic injury during elective laparoscopic tubal ligation at a regional hospital. A vascular injury to the right external iliac artery occurred during the procedure, likely during trochar insertion. The surgeon appropriately converted to open laparotomy and attempted haemorrhage control via packing, consistent with surgical guidelines. However, Mrs Richards' condition became irreversible within 30-60 minutes due to uncontrollable haemorrhage and massive coagulopathy. Clinical lessons include: avoiding excessive trochar insertion pressure during laparoscopy; the critical importance of accurate handover communication during retrieval to ensure appropriate senior staff involvement and theatre readiness; ensuring regional hospitals have massive transfusion protocols and clotting factors available; and surgeons should communicate directly with receiving hospital surgeons regarding iatrogenic injuries.

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

Specialties

general surgerygynaecologyanaesthesiaintensive carevascular surgeryretrieval medicine

Error types

proceduralcommunication

Drugs involved

packed red blood cellsfresh frozen plasmavasoconstrictorsinotropes

Clinical conditions

iatrogenic vascular injuryexsanguinating haemorrhagedisseminated intravascular coagulopathyhypovolaemic shockcoagulopathy

Procedures

laparoscopic tubal ligationveress needle insertiontrochar insertionlaparotomyabdominal packingvascular repairb-lynch haemostatic suture

Contributing factors

  • Iatrogenic injury to right external iliac artery during laparoscopic procedure
  • Uncontrollable haemorrhage with massive coagulopathy
  • Unavailability of clotting factors (FFP, cryoprecipitate, platelets) at regional hospital
  • Miscommunication regarding nature of injury and bleeding status during retrieval
  • Delayed provision of fresh frozen plasma (arrived frozen, requiring thawing)
  • Regional hospital limited capacity for massive transfusion and vascular surgery

Coroner's recommendations

  1. Royal Australasian College of Surgeons should institute guidelines addressing the need for communication between the operating surgeon from the sending hospital and a surgeon at the receiving hospital in circumstances of iatrogenic injury
  2. Royal Australasian College of Surgeons should consider mandatory and regular continuing professional development with both theoretical and practical components for surgeons performing laparoscopic procedures
  3. ARV coordinator should discuss all ICU/HDU retrieval cases with a receiving hospital ICU consultant and not allow cases to be unnecessarily filtered through registrars
  4. Where a patient is in extremis requiring time-critical procedural intervention, access to critical procedure should be the key driver for destination selection
  5. ARV coordinator should advocate for the most appropriate destination based on immediate clinical needs and communicate with receiving consultant-grade staff
Full text
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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.

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