Finding into death of Roy Irvin Dorner
Deceased
Roy Irvin Dorner
Demographics
64y, male
Date of death
2012-10-03
Finding date
2018-03-29
Cause of death
Complications of redo thoracotomy/aortic valve replacement in a man with ischaemic heart disease
AI-generated summary
A 64-year-old physician with significant cardiac history (prior CABG, pacemaker, congestive failure, and newly severe aortic stenosis) underwent redo thoracotomy for aortic valve replacement. During sternal re-entry, the right ventricle was inadvertently incised despite use of an oscillating saw and careful technique. The patient required massive transfusion, ECMO support, and extended surgery but developed multi-organ failure and died 29 days post-operatively. The coroner found the surgery was appropriately indicated, the surgical approach was correct, pre-operative investigations were standard, and informed consent was obtained. Pre-operative CT scanning was not standard practice in 2012 and was not required, though expert opinion differed on whether it might have provided additional anatomical information. Clinical management intra- and post-operatively was appropriate. The death resulted from a known but uncommon complication of complex redo cardiac surgery.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- inadvertent incision of right ventricle during sternotomy despite careful technique
- severely dilated right ventricle with proximity to posterior sternum
- extensive adhesions from prior cardiac surgery
- difficulty establishing cardiopulmonary bypass requiring prolonged emergency manoeuvres
- massive perioperative blood loss requiring extensive transfusion
- prolonged cardiopulmonary bypass
- post-operative multi-organ failure and severe neurological damage
Full text
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