Finding into death of Edis Vytas Brenner
Deceased
Edis Vytas Brenner
Demographics
78y, male
Date of death
2020-02-27
Finding date
2023-06-23
Cause of death
Multiorgan failure consequent upon pulmonary lacerations and haemorrhage sustained during the operative treatment of severe mitral and tricuspid valve disease
AI-generated summary
A 78-year-old man died from multiorgan failure following complications during planned mitral and tricuspid valve surgery. During the initial surgery, a small superficial laceration to the right lower lobe lung occurred, likely from pleural space manipulation or chest drain placement. This resulted in severe unexpected bleeding requiring return to theatre and massive transfusion. The subsequent vasoplegia and multiorgan dysfunction could not be reversed despite appropriate intensive care. The coroner found the death resulted from an uncommon but known surgical risk, with timely and appropriate treatment provided throughout. The main system failure identified was the hospital's failure to report the case to Safer Care Victoria as a sentinel event, representing a missed opportunity for quality improvement and learning.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Intraoperative pulmonary laceration to right lower lobe
- Severe unexpected bleeding from minor lung tear
- Massive transfusion requirement
- Prolonged cardiac bypass
- Severe vasoplegia and multiorgan dysfunction
- Limited preoperative physiological reserve
- Failure to report as sentinel event
Coroner's recommendations
- St John of God Hospital's clinical governance unit should discuss all unexpected deaths that occur in relation to surgery with Safer Care Victoria's Patient Safety Review Team to ascertain whether incidents meet sentinel event notification criteria and make any necessary notifications accordingly
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