Finding into death of Susan Mary Royals
Deceased
Susan Mary Royals
Demographics
74y, female
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.
Error types
Clinical conditions
Contributing factors
- Central venous catheter misplaced in right carotid artery
- Delayed insertion of CVC due to uncertainty regarding procedure progression
- Clinician fatigue at time of CVC insertion
- Limited safety barriers to confirm correct CVC placement
- Limited documentation of CVC insertion on anaesthetic chart
- Right cerebral hemisphere watershed ischaemia following carotid injury
Coroner's recommendations
- Safer Care Victoria develops a standardised approach for CVC insertion which encourages the use of ultrasound guided insertion (and other methods of confirming venous placement) to reduce the likelihood of instances of arterial puncture
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