Deceased
Susan Mary Royals
Demographics
74y, female
Coroner
Coroner Simon McGregor
Date of death
2021-05-22
Finding date
2022-07-26
Cause of death
Complications of carotid artery injury from central line insertion in the setting of surgery for metastatic carcinoma
AI-generated summary
Susan Royals, a 74-year-old woman with metastatic colon cancer, died from complications of carotid artery injury sustained during central venous catheter (CVC) insertion as part of a Whipple procedure and hemicolectomy. The CVC was inadvertently placed in the right carotid artery, leading to right cerebral hemisphere watershed ischaemia despite surgical repair. She subsequently developed multi-organ failure and died. While arterial puncture is a recognised 6-9% complication of CVC insertion, ultrasound guidance—now considered gold standard—was used but not documented. Northern Health implemented comprehensive remedial actions including mandatory safety steps for CVC placement confirmation, standardised documentation, requirement for ultrasound-guided insertion, and multi-disciplinary intra-operative planning. The coroner commended these proactive improvements and made no adverse findings against clinicians.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity
A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with …
0y · Male·subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour
Baby W died within 40 minutes of birth from subgaleal haematoma and subarachnoid haemorrhage following a failed instrumental delivery for prolonged labour. The coroner identified critical missed opportunities in decision…
0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the sett…
Mia Rose Iskander died at 8 hours of age from ascending uterine infection (Klebsiella pneumoniae) with chorioamnionitis following maternal premature pre-labour rupture of membranes (PPROM) at 32 weeks. Maternal managemen…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.