Coronial
VIChospital

Finding into death of PX O

Deceased

PXO

Demographics

49y, male

Coroner

Coroner Simon McGregor

Date of death

2020-03-16

Finding date

2022-05-05

Cause of death

Complications of a right superficial femoral artery injury (operated) following a workplace incident

AI-generated summary

A 49-year-old man died from complications of a right superficial femoral artery injury sustained when he was struck by a circular saw at a landscaping worksite. Despite receiving immediate first aid, emergency transport via helicopter, and aggressive surgical and ICU management including resuscitation, he died from the combined effects of profound blood loss, shock, coagulopathy, and hypoxic brain injury from prolonged cardiac arrest. The deceased was a newly employed labourer who had been instructed not to use power tools but did so against direction. Deficiencies included inadequate formal training documentation, lack of Safe Work Method Statements, and equipment defects (missing safety lock bolt, jammed safety guard). The employer subsequently implemented appropriate compliance measures following WorkSafe improvement notices.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

trauma surgeryvascular surgeryintensive careparamedicineforensic medicine

Error types

systemcommunication

Clinical conditions

superficial femoral artery injuryhypovolaemic shockcardiac arrestcoagulopathymetabolic acidosiscerebral ischaemiahypoxic brain injurymulti-organ failureintra-peritoneal haemorrhageextra-peritoneal haemorrhagegastrointestinal haemorrhage

Procedures

intubationexternal iliac vessel controlsuperficial femoral artery ligationwound washoutcomputed tomographyresuscitation

Contributing factors

  • Lack of formal written training documentation for new employees
  • Inadequate supervision of newly employed worker
  • Worker disregarded explicit instruction not to use power tools
  • Absence of Safe Work Method Statements prior to commencing work
  • Equipment defects: missing bevel lock bolt, jammed safety lock button, non-retracting lower safety guard
  • Saw blade kickback during operation
  • Massive blood loss and shock from vascular injury
  • Prolonged out-of-hospital cardiac arrest with hypoxic brain injury
  • Coagulopathy and ongoing haemorrhage

Coroner's recommendations

  1. Northern Traders to provide documented instruction and training to employees undertaking landscaping works
  2. Northern Traders to provide documented instruction and training on safe operation of power tools
  3. Northern Traders to develop and implement a safe system of work including site-specific hazard identification, risk assessments, and control measures
Full text
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