Coronial
VIChospital

Finding into death of Geoffrey Power

Deceased

GEOFFREY POWER

Demographics

54y, male

Coroner

Coroner Audrey Jamieson

Date of death

2012-10-10

Finding date

2016-02-17

Cause of death

Complications of cervical spinal stenosis treated with cervical laminectomy and fusion in a man with perinatal hypoxic/ischaemic brain injury

AI-generated summary

Geoffrey Power, aged 54, with severe intellectual disability, blindness, and perinatal hypoxic-ischemic brain injury, underwent indicated cervical laminectomy and fusion for cervical stenosis. Post-operatively, he self-removed a drainage tube, then developed a wound infection despite antibiotic treatment. Following repeated hospital readmissions, he developed pneumonia with lung collapse and died from complications of the surgery. Expert review concluded the surgery was appropriate, the self-removal of the drain had no clinical impact, wound infection management was satisfactory, and the death was not preventable. Communication gaps with the family were identified as an opportunity for improvement, particularly regarding clarity on post-operative care expectations and family involvement.

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

Specialties

neurosurgeryintensive careinfectious diseasesemergency medicine

Error types

communication

Drugs involved

antibioticsoral antibiotics

Clinical conditions

cervical spinal stenosisperinatal hypoxic-ischaemic brain injurysevere intellectual disabilityblindnesspost-operative wound infectionpneumonialung collapsecardiac arrest

Procedures

cervical laminectomycervical fusioninternal fixationposterolateral bone graftwound drainageCT scanwound exploration and abscess drainagebronchoscopy

Contributing factors

  • Post-operative wound infection
  • Self-removal of drainage tube
  • Pneumonia with right lung collapse
  • Cardiac arrest

Coroner's recommendations

  1. The coroner determined that matters identified needing clarification had been addressed by Cabrini Hospital and no formal recommendations were necessary.
Full text

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