Finding into death of Giuseppe Costa
Deceased
Giuseppe Costa
Demographics
75y, male
Date of death
2016-10-08
Finding date
2018-06-18
Cause of death
Right haemothorax complicating intercostal catheter insertion for the treatment of right pleural effusion
AI-generated summary
Giuseppe Costa, 75, died from right haemothorax following intercostal catheter insertion for pleural effusion drainage. Critical failures in clinical management included: inadequate documentation of pleural fluid drainage with no clear record of cessation of drainage; removal of the catheter at 7.30pm despite persistent effusion shown on CT scan at 5.50pm; failure to activate MET calls despite vital sign deterioration meeting criteria at 4.00-4.30am; unclear documentation of 'Not for MET Calls' with no indication who wrote it or when; incomplete vital sign recording not compliant with national standards; poor communication of radiological findings to treating clinicians. The catheter likely damaged the intercostal artery, which may have been tamponaded while in situ. Upon removal, uncontrolled bleeding occurred, leading to haemothorax and death. Systemic issues included substandard observation charting, inadequate drainage documentation, and missed opportunities for escalation and clinical intervention.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Contributing factors
- Premature removal of intercostal catheter despite persistent pleural effusion on imaging
- Inadequate documentation of pleural fluid drainage quantities and cessation of drainage
- Failure to activate MET call despite vital sign deterioration meeting MET criteria
- Unclear and undocumented modification of MET call criteria written as 'Not for MET Calls'
- Incomplete recording of vital signs not compliant with national standards
- Poor communication of radiological findings to treating clinicians
- Intercostal artery damage during catheter insertion with subsequent uncontrolled bleeding
- Substandard observation and response charting
- Possible lack of clinician awareness of persistent effusion on imaging
Coroner's recommendations
- Western Hospital Footscray ensure their use of Observation and Response Charts is compliant with the Australian Commission on Safety and Quality in Health Care's National Standards
- Western Hospital Footscray peruse this Finding to improve their overall management of drainage of pleural effusions, including ensuring adequate documentation of the management of drainage of pleural effusions
- Western Hospital Footscray explore opportunities to educate all clinical staff to improve their interpretation of chest X-ray results
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