Finding into death of H YR
Deceased
HYR
Demographics
77y, female
Date of death
2018-09-27
Finding date
2022-02-28
Cause of death
Haemoperitoneum following cholecystectomy
AI-generated summary
A 77-year-old woman died from haemoperitoneum (intra-abdominal bleeding) three days after elective laparoscopic cholecystectomy. Bleeding from the left inferior epigastric artery was a recognised surgical complication but was not identified until 12:14 pm on day 3, despite clinical signs from 9:30 am. Key failures included: delayed CT imaging (90 minutes after MET call), inadequate fluid and blood resuscitation (only 1 unit PRBC over 2 hours despite confirmed haemorrhage), failure to check coagulation status until 7:45 pm despite therapeutic anticoagulation, lack of urinary catheter insertion until 8:00 pm, delayed antibiotic administration, and poor inter-team communication and documentation. The coroner found the patient likely would have survived with earlier diagnosis and aggressive resuscitation, though angioembolisation rather than open laparotomy was performed.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Delayed identification of intra-abdominal bleeding
- Delayed CT imaging (90 minutes after MET call identified need)
- Inadequate fluid resuscitation
- Inadequate blood product administration (only 1 unit over 2 hours despite active haemorrhage)
- Failure to check coagulation status promptly despite therapeutic anticoagulation
- Delayed urinary catheter insertion (8:00 pm vs 12:30 pm when planned)
- Delayed antibiotic administration despite sepsis flagged at multiple MET calls
- Lack of monitoring during interventional radiology procedure (2 hours without observations)
- Poor inter-team communication and coordination
- Inadequate medical record keeping and documentation
- Delay in commencing angioembolisation procedure
- Therapeutic anticoagulation with enoxaparin and warfarin transition
Coroner's recommendations
- Reports HYR's death to Safer Care Victoria as a sentinel event under category 11 (all other adverse patient safety events resulting in serious harm or death)
- Conducts an external review of the capacity and capability of its interventional radiological service to monitor patients and provide resuscitation, including fluids, and reports the results to Safer Care Victoria
- Undertakes open disclosure with HYR's family in accordance with the Australian Open Disclosure Framework
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