Coronial
VIChospital

Finding into death of Kenneth Ernest O'Brien

Deceased

Kenneth Ernest O'Brien

Demographics

74y, male

Coroner

Coroner Audrey Jamieson

Date of death

2017-09-13

Finding date

2022-10-18

Cause of death

Intra-abdominal haemorrhage complicating elective umbilical hernia repair

AI-generated summary

A 74-year-old man with significant cardiac history (atrial fibrillation, dilated cardiomyopathy, pacemaker) underwent elective umbilical hernia repair. Intraoperatively, unexpected ascites was discovered and partially drained. Postoperatively, he developed hypotension and was transferred to ICU. The coroner found that post-operative intra-abdominal haemorrhage was not recognised early enough. Critical factors included: over-reliance on a single haemoglobin result to exclude bleeding; failure to recognise that haemoglobin doesn't fall immediately in acute bleeding; inadequate communication from ICU staff about escalating vasopressor requirements between midnight and 5am; and failure to withhold anticoagulation or give fresh frozen plasma earlier. The patient's underlying chronic liver disease (from severe tricuspid regurgitation) created an unrecognised coagulopathy risk. Earlier recognition and aggressive management might have allowed exploratory laparotomy and bleeding control.

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

Specialties

general surgeryanaesthesiaintensive caregeneral medicinenephrologycardiology

Error types

diagnosticcommunicationdelay

Drugs involved

apixabannoradrenalinevasopressin

Clinical conditions

intra-abdominal haemorrhageatrial fibrillationdilated cardiomyopathysick sinus syndrometricuspid regurgitationventricular tachycardialiver fibrosiscongestive hepatopathycoagulopathyhypotensionshockascitesileus

Procedures

umbilical hernia repairascitic fluid drainagecentral venous line insertionarterial line insertionexploratory laparotomy (not performed)

Contributing factors

  • Dilated cardiomyopathy
  • Liver fibrosis
  • Unrecognised coagulopathy secondary to chronic liver disease
  • Late recognition of post-operative haemorrhage
  • Over-reliance on single haemoglobin result to exclude bleeding
  • Inadequate communication from ICU team regarding escalating vasopressor requirements
  • Failure to withhold anticoagulation postoperatively
  • Delayed recognition of post-operative complications
  • Mesh detachment from abdominal wall

Coroner's recommendations

  1. Enhanced communication protocols between ICU and surgical teams regarding escalating vasopressor requirements and patient deterioration
  2. Improved recognition of post-operative bleeding through consideration of clinical trajectory rather than reliance on single biochemical results
  3. Better assessment of coagulopathy risk in patients with liver disease prior to elective surgery
  4. Consideration of withholding anticoagulation for 24-48 hours post-operatively in high-risk bleeding scenarios
  5. Earlier threshold for suspecting post-operative haemorrhage when vasopressor requirements escalate
Full text
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