Finding into death of John Richard Connelly

Contributing factors

• Compound open femoral fracture with massive external bleeding
• Warfarin anticoagulation markedly decreasing haemorrhage control
• Haemorrhagic shock with predicted mortality >90% on paramedic arrival
• Isolated rural location 300km from trauma centre
• Delayed recognition of rebleeding during flight due to confined HEMS aircraft design and task saturation
• Insufficient blood products available (2 units transfused, estimated 10 units required)
• Correction of hypovolaemia leading to increased blood pressure and rebleeding
• Pre-existing ischaemic heart disease and multiple comorbidities

Coroner's recommendations

1. Ambulance Victoria review hypovolaemia guidelines CPG A0801 and CPG AAV-08 to make specific note of the risk of re-bleeding from previously controlled bleeding sites associated with penetrating trauma when correcting hypovolaemia
2. Ambulance Victoria review hypovolaemia guidelines CPG A0801 and CPG AAV-08 to make specific note of the need to continuously assess the effectiveness of haemorrhage control following attempts to correct hypovolaemia
3. Ambulance Victoria and Trauma Victoria develop consistent practice guidelines pertaining to trauma patients across the prehospital and hospital setting