Finding into death of H YR

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

1. 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)
2. 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
3. Undertakes open disclosure with HYR's family in accordance with the Australian Open Disclosure Framework