Finding into death of Ann Leah Jones

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

1. Delay anaesthesia induction until the surgeon arrives in the operating theatre to reduce prolonged pre-operative sedation time
2. Delay floating the Swan-Ganz balloon catheter until the patient is intubated and sternotomy has commenced
3. 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
4. Provide training for anaesthetic nursing staff to escalate concerns to the anaesthetist when subtle changes in haemodynamic parameters are observed
5. Consider use of intubation practice simulation models and structured training for anaesthetic nursing teams to improve recognition and escalation of haemodynamic changes