Coronial
VIChospital

Finding into death of Kevin Patrick O'Keeffe

Deceased

Kevin Patrick O'Keeffe

Demographics

82y, male

Coroner

Coroner Audrey Jamieson

Date of death

2017-02-05

Finding date

2018-05-28

Cause of death

Cardiomegaly, myocardial fibrosis and ischaemic coronary artery disease in the context of large bowel resection for argon plasma coagulation perforations during a colonoscopy

AI-generated summary

An 82-year-old man with extensive comorbidities underwent colonoscopy with argon plasma coagulation (APC) for bleeding angiodysplasia. Prolonged activation intervals during the final third of the procedure caused full-thickness bowel burns and colonic perforation, necessitating emergency surgery. He subsequently died from multi-organ failure in the context of his pre-existing severe cardiovascular disease (cardiomegaly, myocardial fibrosis, triple-vessel ischaemic coronary disease). The gastroenterologist was experienced but had received training only in equipment operation, not procedural technique—specifically, the 'spotwise' technique for treating extensive angiodysplasia. The coroner found that technique directly contributed to complications. Clinical lessons include: (1) standardised training must address procedural technique, not just equipment; (2) complex angiodysplasia may require limiting lesions treated per procedure; (3) difficult-to-control bleeding should prompt consideration of surgical referral; (4) multidisciplinary pre-procedure review of high-risk cases is essential; (5) regular audit of complications and performance indicators should be implemented.

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

Specialties

gastroenterologysurgerycardiologyintensive caregeneral medicine

Error types

proceduralcommunicationsystem

Drugs involved

noradrenalinefurosemidemilrinonevasopressin

Clinical conditions

angiodysplasiagastrointestinal bleedingcolonic perforationcardiomegalymyocardial fibrosisischaemic coronary artery diseasepulmonary hypertensionpulmonary fibrosischronic obstructive pulmonary diseasechronic renal failureatrial fibrillationanaemiamulti-organ failure

Procedures

colonoscopyargon plasma coagulationemergency laparotomyileocolic resection with primary anastomosis

Contributing factors

  • Prolonged activation intervals during argon plasma coagulation procedure
  • Lack of training in procedural technique ('spotwise' technique)
  • Treatment of extensive angiodysplasia without limiting number of lesions
  • Lack of protocol for complex endoscopic procedures
  • Lack of multidisciplinary pre-procedure planning
  • Difficult-to-control bleeding during procedure
  • Pre-existing severe cardiovascular disease
  • Emergency surgery required due to colonic perforation

Coroner's recommendations

  1. The Therapeutic Goods Administration should review the circumstances of Mr O'Keeffe's death
  2. The Therapeutic Goods Administration should review the Ballarat Health Services Governance and Risk Management Unit Investigation Report conclusions and recommendations
  3. The Therapeutic Goods Administration should consider whether the manufacturer has met the relevant Australian Essential Principles in relation to the CONMED CE200 Beamer Electrosurgical System
  4. BHS should develop a clinical protocol for use of the machine including CONMED advice for use
  5. The protocol must address treatment of angiodysplasia and endorse the 'spotwise' technique for larger areas
  6. The protocol must mandate treatment of only one or two lesions during a complex procedure with extensive angiodysplasia
  7. The protocol must state that patients with difficult-to-control bleeding should be referred for surgical management
  8. The protocol must dictate training and competency requirements
  9. The protocol must require Key Performance Indicators (KPIs)
  10. BHS should undertake target six-monthly audit of endoscopy patient medical records including APC procedures to identify complications and monitor KPIs
  11. BHS should create a regular formalised process to discuss complex or high-risk patients prior to treatment, such as multidisciplinary meetings between gastroenterologists and surgeons
  12. BHS Medical Credentialing and Advisory Committee should discuss whether uncommon procedural techniques ought to be included in Advanced Scope of Practice Procedures
  13. A BHS gastroenterologist representative should attend surgical mortality and morbidity meetings quarterly to present and discuss audit results, KPIs and complications
Full text
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