VIChospital

Finding into death of Shane Hughes

Deceased

Shane Hughes

Demographics

40y, male

Coroner

Deputy State Coroner Paresa Spanos

Date of death

2018-07-13

Finding date

2024-10-29

Cause of death

Acute hepatic and renal failure in the setting of postoperative haemorrhage following elective nephrectomy for renal cell carcinoma

AI-generated summary

A 40-year-old man with obesity, COPD, diabetes and hypertension died from acute hepatic and renal failure following postoperative haemorrhage after left radical nephrectomy for a 10cm renal cell carcinoma. The surgeon applied a vascular stapler to the renal hilum en masse without visualising individual vessels, likely missing the inferior branch of the left renal artery and inadvertently ligating the superior mesenteric artery. Critical lessons include: complex large tumours require appropriate surgical approach (open vs laparoscopic) determined by tumour size and distorted anatomy; individual vessel identification and ligation is safer than mass stapling when vessels cannot be visualised; early recognition of slow postoperative bleeding (elevated potassium suggesting ischaemia) and escalation to theatre may improve outcomes; multidisciplinary team recommendations must be followed and properly documented; and high-risk patients require senior surgeon involvement and appropriate facility planning.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

urologysurgeryanaesthesiaintensive carevascular surgery

Error types

proceduraldiagnosticcommunicationsystem

Drugs involved

metaraminol

Clinical conditions

renal cell carcinomapostoperative haemorrhageacute kidney injuryacute liver failurebowel ischaemiaobesitytype 2 diabetes mellituschronic obstructive pulmonary diseasehypertensioncoronary artery atherosclerosisoliguria/anuriahyperkalaemiaacidosis

Procedures

radical left nephrectomylaparoscopic surgeryvascular stapling of renal hilumconversion to open procedure (partial)

Contributing factors

Postoperative bleeding from inferior branch of left renal artery not ligated within staple line
Inadvertent ligation of superior mesenteric artery causing bowel ischaemia
Mass hilar stapling without visualisation of individual vessels
Failure to convert to open procedure when hilar vessels could not be visualised laparoscopically
Delayed recognition of slow postoperative bleed
Failure to appreciate elevated potassium as indicator of ischaemia
Obesity (BMI 41)
Coronary artery atherosclerosis
Chronic obstructive pulmonary disease
Inadequate multidisciplinary team planning and documentation
Non-compliance with institutional policy regarding caution for laparoscopic tumours >7cm

Coroner's recommendations

Monash Health's Surgery & Interventional Services Program to investigate how processes can be designed and implemented to ensure that recommendations from previous adverse events are followed and embedded into usual practice
Monash Health Urology to review the MDT meeting process and develop structured procedures including: structured approach for each case presentation; discussion of appropriate site for surgery and surgical approach; designated minute taker for documentation; MDT decisions not to be changed without further MDT discussion; MDT results emailed to allocated surgeon prior to surgery; and revised MDT meeting template
Monash Health Urology to review appropriate use of staples and Surgicel to control intraoperative bleeding
Monash Health to develop guidelines for consultants to attend onsite for bedside review of deteriorating patients during and out of business hours
Monash Health Urology Team to review Shane's case and coroner's report to ensure early consideration and recognition of slow postoperative bleed
Anaesthetic review to ensure optimal resuscitation and stabilisation of unwell patients for transfer
Anaesthetic review to ensure transfer guidelines are adequate
Review of after-hours medical cover at Moorabbin Hospital including seniority of rostered staff

Full text

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