Coronial
VIChospital

Finding into death of Brett Maybus

Deceased

Brett Maybus

Demographics

60y, male

Coroner

Coroner Phillip Byrne

Date of death

2017-08-29

Finding date

2020-01-31

Cause of death

Haemorrhage complicating a left robotic upper mediastinal lymph node clearance in a man with metastatic squamous cell carcinoma, secondary to rupture of a blood vessel compromised by previous radiation therapy

AI-generated summary

Brett Maybus, aged 60, died from massive haemorrhage following robotic mediastinal lymph node dissection for recurrent metastatic squamous cell carcinoma. The coroner found the fatal bleed was likely caused by rupture of a blood vessel compromised by previous high-dose radiotherapy to that region. The critical clinical lesson concerns informed consent: while the patient was a well-informed, intelligent man who consented to surgery, the surgeons did not adequately disclose the specific heightened risk of vascular damage from prior radiation in that anatomical zone. The coroner noted this was a material risk that should have been explicitly conveyed to enable fully informed consent. Although the coroner concluded the patient would likely have consented anyway given his limited curative options, the failure to document and specifically discuss this radiation-specific risk in medical records represents a preventable gap in the consent process.

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

Specialties

cardiothoracic surgeryoncologyradiation oncologyanaesthesia

Error types

communicationsystem

Clinical conditions

Metastatic squamous cell carcinomaStage III squamous cell carcinoma (post-pneumonectomy)Supraglottic squamous cell carcinomaMediastinal lymph node recurrenceRadiation-induced vascular injurySevere atherosclerotic coronary artery diseaseMyocardial fibrosisPulmonary fibrosisPulmonary hypertensionCardiac arrestHaemorrhagic shock

Procedures

Robotic mediastinal lymph node dissectionEmergency thoracotomyCardiac resuscitation

Contributing factors

  • Failure to adequately disclose heightened risk of vascular damage from previous radiotherapy
  • Inadequate documentation of risk discussions in medical records
  • Assumption that patient's awareness of prior chest irradiation was sufficient to convey specific vascular risk
  • Severe ischaemic heart disease (85-95% coronary artery stenosis) may have contributed to inability to resuscitate
  • Rupture of blood vessel in heavily irradiated mediastinal region

Coroner's recommendations

  1. Document discussions regarding attendant risks of proposed procedures in medical records, particularly risks specific to the individual patient
  2. Consider audio recording of risk disclosure discussions to provide contemporaneous evidence if consent issues subsequently become contentious
  3. Surgeons should explicitly disclose heightened vascular risks when operating in previously heavily irradiated fields, rather than assuming patient awareness of prior radiation is sufficient
  4. Consent processes should specifically address patient-specific (subjective) risks in addition to general procedural risks, and these discussions should be documented
Full text
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