Finding into death of Md Fakrul Alam Sozon
Deceased
Md Fakrul Alam Sozon
Demographics
33y, male
Date of death
2020-10-10
Finding date
2023-08-14
Cause of death
Haemoperitoneum secondary to lacerated spleen as a result of peritoneal ascitic fluid tap procedure, on a background of liver failure with veno-occlusive liver disease
AI-generated summary
A 33-year-old man with severe alcoholic liver disease (Child-Pugh C) and poor prognosis died from haemoperitoneum following splenic laceration during a diagnostic ascitic tap procedure. Two junior doctors (HMOs/Basic Physician Trainees) performed the procedure unsupervised without formal ultrasound training, mistaking the spleen for ascitic fluid. Critical failures included: absence of senior supervision despite protocol suggesting registrar oversight, lack of formal ultrasound competency training and credentialling, failure to use percussion technique as per protocol, and misinterpretation of ultrasound imaging. While the coroner found no adverse findings against the junior doctors who acted under instruction and appropriately abandoned the procedure when complications arose, significant clinical governance failures were identified. The coroner could not find the death preventable given the patient's terminal prognosis, but emphasised missed opportunities for appropriate care and recommended formal ultrasound training and credentialling systems.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Absence of senior supervision during procedure
- Lack of formal ultrasound training and accreditation for junior medical staff
- Misinterpretation of ultrasound imaging - spleen mistaken for ascitic fluid
- Failure to use percussion technique as per protocol
- No formal competency credentialling system in place
- Competing clinical demands on supervising registrar
- Severe underlying liver disease with poor coagulation
- Lack of palliative care consultation earlier in admission
Coroner's recommendations
- Western Health should develop a formal internal training and credentialling system regarding the use of bedside ultrasound for ascitic taps so that the technology can be used by clinicians other than trained radiology staff where necessary and appropriate
- Development of an organisational procedure to guide the safe performance of ascitic tap procedures
- Development of an ascitic tap competency framework
- Promotion of referral to specialist teams such as palliative care services to ensure appropriate patient management
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