Deceased
Nicola Deleo
Demographics
91y, male
Coroner
Coroner Sarah Gebert
Date of death
2018-12-09
Finding date
2020-09-29
Cause of death
Complications following cardiac arrest in the setting of anaesthetic induction during surgery for the treatment of small bowel obstruction due to a right inguinal hernia
AI-generated summary
A 91-year-old man with COPD, asthma, and previous cardiac arrest from suxamethonium died from complications following anaphylaxis to rocuronium during anaesthetic induction for emergency small bowel obstruction surgery. His GP records documented allergy to both suxamethonium and vecuronium (a non-depolarising blocker in the same class as rocuronium used), but this critical allergy information was not included in the hospital referral form sent 9 months earlier. The anaesthetic management and emergency surgery were clinically appropriate given life-threatening pathology. However, the absence of complete allergy information at the time of surgery represented a potential gap in care. The coroner recommended improving hospital referral templates to ensure allergies are consistently captured and communicated to reduce future iatrogenic harm.
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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Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…
17y · Male·Hypoxic Ischaemic Encephalopathy Complicating Anaphylaxis
James Tsindos, a 17-year-old with known nut allergy and mild asthma, experienced anaphylaxis after inadvertently ingesting cashews in a vegan restaurant meal on 27 May 2021. Ambulance paramedics administered two doses of…
15y · Male·Cardiorespiratory arrest of unknown aetiology complicating hypoxic ischaemic enc…
Max McKenzie, a 15-year-old with asthma and food allergies, died from cardiorespiratory arrest complicating hypoxic ischaemic encephalopathy after severe refractory anaphylaxis. After eating apple crumble containing nuts…
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