Finding into death of Warren Douglas Frazer
Deceased
Warren Douglas Frazer
Demographics
45y, male
Date of death
2018-09-27
Finding date
2022-10-18
Cause of death
Complications of VATS procedure for locally advanced right upper lobe lung adenocarcinoma
AI-generated summary
A 45-year-old man died from complications following VATS lobectomy for lung adenocarcinoma. During initial surgery, the tumour invaded the T6 vertebral body. The surgeon, faced with incomplete tumour resection or vertebral body excision, chose to remove part of the vertebra. Post-operative spinal cord compression from haematoma required emergency laminectomy, but an 8-hour delay may have worsened neurological outcomes. Subsequent complications included tracheopleural fistula, recurrent fistula despite multiple repairs, and aerocephalus. The coroner found the surgeon's intraoperative decision reasonable given the clinical dilemma, but identified systemic gaps: inadequate pre-operative imaging to detect vertebral invasion, lack of intraoperative neurosurgical support at the primary hospital, delayed family communication, and informal inter-hospital transfer arrangements. Key lessons include obtaining advanced imaging when tumour location suggests vertebral involvement, establishing protocols for urgent neurosurgical consultation, formalising hospital transfer agreements, and improving family communication during prolonged surgery.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Tumour invasion of T6 vertebral body not detected on pre-operative imaging
- Intraoperative discovery of vertebral body invasion requiring difficult surgical decision
- 8-hour delay from recognition of spinal cord compression to laminectomy
- Post-operative epidural haematoma causing spinal cord compression
- Tracheopleural fistula development post-decortication
- Recurrent fistula despite multiple surgical repairs
- Aerocephalus (air in cerebrospinal fluid) from fistula communication with subarachnoid space
- Lack of intraoperative neurosurgical support at primary hospital
- Informal inter-hospital transfer arrangement delaying definitive neurosurgical management
Coroner's recommendations
- The Northern Hospital implement a formal policy describing how family members and next of kin are to be kept informed about surgery progress, particularly when surgery takes longer than estimated.
- The Northern Hospital formalise arrangements for transferring patients to St.Vincent's Hospital or The Austin Hospital and document those arrangements in a protocol agreed upon by the hospitals.
- The Northern Hospital audit compliance with the Cancer Optimal Care Pathway in relation to peri-operative investigations and planning.
- The Northern Hospital audit the effectiveness of the Head of Thoracic Surgery and newly appointed full-time Thoracic Surgeon in providing timely assistance and support to thoracic and other surgeons.
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