HOGGINS Cheryl
Deceased
Cheryl Hoggins
Demographics
48y, female
Date of death
2000-07-01
Finding date
2003-03-18
Cause of death
Cardiorespiratory arrest due to cardiac tamponade as a result of perforation of the heart following central venous catheterization
AI-generated summary
Cheryl Hoggins, aged 48, died on 1 July 2000 from cardiac tamponade following perforation of the right atrium during central venous catheter exchange in ICU. She was recovering from emergency liver transplantation complicated by sepsis and acute renal failure. A routine guidewire exchange of her hemodialysis catheter on 29 June inadvertently placed the new catheter in the right atrium. A junior doctor was advised by a senior registrar that checking via X-ray was unnecessary, based on one research article. The misplaced catheter went undetected for 27 hours. An early morning X-ray would have shown the problem but was not reviewed when the patient transferred units—a system error. The coroner found the death potentially preventable had proper procedures been followed. Key lessons: always verify catheter placement per manufacturer and hospital protocols; ensure diagnostic tests are reviewed during ward transfers; supervise junior clinicians on best-practice procedures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Inadvertent placement of central venous catheter in right atrium during guidewire exchange on 29 June 2000
- Failure to perform check X-ray after catheter exchange procedure
- Senior clinician advised junior doctor that check X-ray was unnecessary based on single research article
- Non-compliance with hospital procedures and manufacturer instructions requiring catheter position verification
- Failure to review early morning X-ray (6am 30 June) that demonstrated catheter malposition
- System error: X-ray not reviewed due to patient transfer from ICU to high dependency unit overnight
- Delay in identifying and correcting catheter position—27 hours from insertion to death
Coroner's recommendations
- Hospital documented procedures should ensure that following insertion, manipulation or exchange of a central venous catheter, chest radiography or fluoroscopy is routinely performed and reviewed to confirm satisfactory tip position in a timely manner
- Austin Hospital develop procedures for checking X-rays by clinicians to ensure system errors are avoided, particularly when patients transfer between wards, and that diagnostic test reviews are not lost during transfers
- Circumstances surrounding chart alteration be disseminated to medical and nursing professions with warning that alterations should not be made without appropriate documentation of time, date, reason, and identity of person making alteration
- Austin Hospital review generic chart design and layout to minimize confusion in reading figures caused by printed lines, with findings disseminated to other Victorian hospitals
- Staff in all hospitals be advised of the unclear numbering issue and the need to write figures clearly and legibly on charts
- Department of Human Services undertake major research project to identify extent of iatrogenic injury and death associated with failure to follow product manufacturer instructions, warnings or guidelines in hospital settings, in cooperation with medical colleges and accident research centers
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —