Finding into death of Ann Leah Jones
Deceased
Ann Leah Jones
Demographics
87y, female
Date of death
2020-02-14
Finding date
2022-03-15
Cause of death
Pulmonary artery rupture complicating pulmonary artery catheter insertion in a woman with severe ischaemic heart disease
AI-generated summary
Mrs Jones, an 87-year-old woman with severe ischaemic heart disease, died from pulmonary artery rupture during elective off-pump coronary artery bypass surgery. A Swan-Ganz pulmonary artery catheter (PAC) was inserted pre-operatively for haemodynamic monitoring. Approximately 45 minutes later, at anaesthetic induction, moderate blood was observed in her oral cavity—a known clinical sign of PAC-related pulmonary artery injury. Despite intubation and resuscitation attempts, she developed massive pulmonary haemorrhage, hypoxia, and cardiac arrest. An intra-aortic balloon pump inserted during resuscitation caused secondary aortic rupture in her severely atherosclerotic aorta. The coroner found the medical care reasonable but noted institutional improvements: delaying PAC balloon flotation until after sternotomy, delaying anaesthesia induction until surgeon arrival, and improving staff awareness of subtle haemodynamic parameter changes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Aortic rupture complicating balloon pump insertion during resuscitation for cardiac arrest
- Severe atherosclerotic aorta with markedly friable tissue
- Advanced age (87 years) with multiple cardiac comorbidities
- Prolonged sedation prior to intubation allowing undetected blood pooling
- Approximately 45-minute delay between PAC insertion and intubation
- Multiple attempts required to insert intra-aortic balloon pump correctly
Coroner's recommendations
- Delay anaesthesia induction until the surgeon arrives in the operating theatre to reduce prolonged pre-operative sedation time
- Delay floating the Swan-Ganz balloon catheter until the patient is intubated and sternotomy has commenced
- Increase anaesthetic staff awareness of subtle changes in patient haemodynamic parameters (pulmonary artery pressure, blood pressure, carbon dioxide levels) and implement earlier investigation and preventative measures
- Provide training for anaesthetic nursing staff to escalate concerns to the anaesthetist when subtle changes in haemodynamic parameters are observed
- Consider use of intubation practice simulation models and structured training for anaesthetic nursing teams to improve recognition and escalation of haemodynamic changes
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