Deceased
Lydia Maxfield
Demographics
85y, female
Coroner
Coroner Audrey Jamieson
Date of death
2016-02-22
Finding date
2020-07-16
Cause of death
Multisystem failure complicating ischaemic heart disease and ischaemic bowel in the setting of recent total knee replacement
AI-generated summary
Lydia Maxfield, 85, died 5 days after elective left total knee replacement at a private hospital from multisystem failure due to ischaemic heart disease and ischaemic bowel. Critical clinical lessons: (1) Multiple abnormal vital signs (low oxygen saturation, hypotension) occurring post-operatively were not escalated appropriately according to hospital observation protocols despite documented variances. (2) Poor communication between surgical and medical teams prevented unified assessment; the operating surgeon was not informed of clinical deterioration over the weekend. (3) Medical reviews by multiple clinicians (anaesthetist, general physician) were not documented in the medical record. (4) Post-operative anti-emetics were continued despite persistent nausea without consulting the anaesthetist as per protocol. (5) Care pathway variances were not discussed with the surgeon. Earlier escalation following observation protocol guidelines, comprehensive medical review including imaging, and better interdisciplinary communication may have enabled timely diagnosis of bowel ischaemia and intervention.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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