Finding into death of Ruth Ann McKenna

Contributing factors

• Underestimation of medical complexity, particularly unrecognised right ventricular hypertrophy and probable pulmonary hypertension
• Absence of pre-operative specialist hepatology review despite severe liver disease
• Absence of pre-operative specialist cardiology review and collaboration
• Surgery commenced without immediate access to platelets despite thrombocytopenia (platelet count 51)
• Lack of documentation and review of pre-operative investigations during PAC homework session
• Cervical stenosis preventing use of standard cervicovaginal delineator instrument
• Complex pelvic and abdominal adhesions not fully anticipated
• Excessive intraoperative blood loss (2000-2500mls vs expected 150-200mls)
• Limited cardiovascular response to blood loss due to underlying cardiac disease
• Inadequate communication between pre-anaesthetic clinic and surgical team
• Disseminated intravascular coagulation secondary to blood loss, cirrhosis and coagulopathy

Coroner's recommendations

1. Goulburn Valley Health should review policies to ensure patients are not placed on waiting list for surgery until final sign off of all investigations requested during pre-anaesthetic consultation
2. Goulburn Valley Health should work with echocardiography services to streamline assessments for patients with reduced exercise tolerance and possible underlying cardiac problems
3. Goulburn Valley Health should review the system of communication between pre-anaesthetic clinic and surgical teams to ensure surgeons are apprised of PAC review outcomes, management plans and requests for further investigations
4. Royal Australian and New Zealand College of Obstetricians and Gynaecologists should liaise with Department of Health to explore development of a laparoscopic surgery database within Victoria to enhance quality and accountability, enabling access to live outcome data, feedback to clinicians, targeted training, and recommendations regarding service capability