Deceased
Paul Turner
Demographics
73y, male
Coroner
Deputy State Coroner Jacqui Hawkins
Date of death
2018-08-05
Finding date
2022-06-06
Cause of death
Haemorrhagic stroke in the setting of recent inguinal hernia surgery and change in anticoagulation therapy
AI-generated summary
Paul Turner, 73-year-old with atrial fibrillation and aortic valve replacement, underwent elective bilateral inguinal hernia repair in August 2018. His cardiologist advised ceasing rivaroxaban 3-4 days preoperatively; however, he ceased it six days before surgery (timing unclear). Critically, rivaroxaban was not charted in the post-operative period despite the surgeon's verbal instructions to nursing staff alone. A post-operative review two days post-surgery was not documented. Turner suffered an acute ischaemic stroke on postoperative day 2 that underwent haemorrhagic transformation following thrombolysis, resulting in death. Key failures included: failure to chart anticoagulation post-operatively (prescribing omission error), inadequate post-operative review documentation, lack of communication regarding the earlier-than-planned cessation of anticoagulation, and absence of pre-discharge pharmacy review. Clinical lessons include the critical importance of explicit written post-operative medication charting, multidisciplinary communication in anticoagulation management during surgery, and timely clinical review with documentation.
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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