Coronial
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Finding into death of Andrew John O'Dwyer

Deceased

Andrew John O'Dwyer

Demographics

51y, male

Coroner

Coroner Caitlin English

Date of death

2015-09-12

Finding date

2018-08-30

Cause of death

Exsanguination during home haemodialysis in a man with end stage renal failure

AI-generated summary

A 51-year-old man with end-stage renal failure died from exsanguination during home haemodialysis. The most likely cause was a procedural error where Mr O'Dwyer connected his dialysis machine's venous line to the venous drain bag instead of to the venous needle, and then activated the blood pump, causing rapid blood loss into the bag. This may have been a deliberate 'short-cut' to reduce saline load—a practice known among experienced dialysis patients despite training advice against it. The machine's failsafe optical detector either was not engaged or was overridden. Clinicians should recognize that home dialysis patients may take dangerous shortcuts despite training, and that manufacturers should design machines with stronger safeguards for home use. Better scene preservation at medical emergencies is also important for learning from such events.

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

Specialties

nephrologyemergency medicine

Error types

proceduralsystem

Clinical conditions

end-stage renal failureexsanguinationarteriovenous fistula complicationsanuric kidney disease

Procedures

home haemodialysisarteriovenous fistula cannulationextracorporeal circuit priming

Contributing factors

  • Connection of venous blood line to venous drain bag instead of venous needle
  • Activation of blood pump with improper line configuration
  • Possible failure to properly seat venous line in optical detector
  • Patient may have intentionally taken a 'short-cut' to reduce saline load despite training against this
  • Absence of supervising medical and nursing staff in home setting
  • Machine failsafe mechanisms may have been overridden or not engaged

Coroner's recommendations

  1. Safer Care Victoria should review the safety of haemodialysis machines used by home haemodialysis patients supported by Victorian public health services, with particular focus on failsafe mechanisms and ways to avoid potentially dangerous short cuts when used in the home setting
  2. Ambulance Victoria and Victoria Police should be advised to preserve dialysis machine setup at scenes of home haemodialysis emergencies—turning off the machine at wall plug and double-clamping then cutting lines near skin sites, without dismantling the system, to preserve evidence for expert assessment
  3. Paramedic and police training should regard home dialysis death scenes as medical scenes for learning rather than crime scenes, and should ensure untouched machine setup photography and expert dialysis team early access
  4. Fresenius Medical Care should consider design of safety features in haemodialysis machines specifically for home use, including failsafes that prevent blood pump activation without proper optical detector engagement
Full text
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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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