Coronial
VIChospital

Finding into death of Judith Elizabeth Heath

Deceased

Judith Elizabeth Heath

Demographics

68y, female

Date of death

2006-09-07

Finding date

2012-01-31

Cause of death

Massive blood loss due to disconnection of haemodialysis machine

AI-generated summary

Judith Heath, age 68, died from acute blood loss on 7 September 2006 at The Alfred Hospital during routine haemodialysis for end-stage renal failure. The Luer-Lok connection between her arteriovenous catheter and the haemodialysis machine became disconnected at approximately 2:20pm. Critically, neither the machine's alarm system triggered nor did the pump stop automatically, allowing blood to pump out at 250ml/minute for approximately 16 minutes before discovery. This case illustrates multiple failures: possible improper Luer-Lok connection, failure of pressure-based alarm systems to detect disconnection, and absence of independent physiological monitoring. The coroner identified system and equipment design failures and made recommendations for safety improvements including wetness detectors, Luer-Lok standardization, and independent physiological monitoring systems. Broader context included Mrs Heath's stress from extensive ambulance travel and delays in accessing satellite dialysis units closer to home.

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

Specialties

nephrology

Error types

proceduralsystem

Drugs involved

heparin

Clinical conditions

end-stage renal failurediabetes mellitus type 1diabetic nephropathyhyperkalaemiaanaemiaacute myocardial infarctiontriple vessel ischaemic coronary artery diseasecardiac enlargementdiabetic retinopathydiabetic neuropathy

Procedures

haemodialysisarteriovenous fistula creationcentral line insertioncoronary artery angioplasty and stenting

Contributing factors

  • Disconnection of Luer-Lok connection between haemodialysis machine and arteriovenous catheter
  • Failure of alarm system to trigger when disconnection occurred
  • Failure of haemodialysis pump to stop automatically when disconnection occurred
  • Possible improper connection or failure of Luer-Lok fitting
  • Lack of independent physiological monitoring systems
  • Possible human error in connecting or reconnecting Luer-Lok
  • Underlying triple vessel ischaemic coronary artery disease

Coroner's recommendations

  1. The Alfred Dialysis Unit and Ambulance Victoria cooperate to develop an ongoing communication strategy for elderly haemodialysis patients and their relatives to better inform them about the stressors associated with haemodialysis, the way in which their ambulance transport arrangements are managed and the times they can expect to be picked up from and delivered home
  2. Dialysis Coordinators at Hub Dialysis Units in Melbourne cooperate with each other and with Ambulance Victoria to coordinate placement of patients in overlapping regional areas to reduce the incidence of delayed ambulance response times and the length of ambulance trips for haemodialysis patients
  3. The Therapeutic Goods Administration review the compatibility and standards of Luer-Lok connectors used in haemodialysis with a view to issuing a warning about the serious consequences of undetected failures
  4. The Alfred and other haemodialysis units use a wetness detector with their Luer-Lok connectors to prevent undetected leaks arising from failure or disconnections
  5. Fresenius Medical Care develop and integrate an emergency response system into their haemodialysis machines to independently detect decline in the patient's physiological condition, trigger an audible alarm and stop the pump
Full text
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Source and disclaimer

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