Coronial
WAhospital

Inquest into the Death of Aslett, Wendy May

Deceased

Wendy May Aslett

Demographics

60y, female

Date of death

2010-10-29

Finding date

2013-01-17

Cause of death

Multiple organ failure following hemorrhage from penetration of the femoral artery

AI-generated summary

Wendy May Aslett, aged 60, died on 29 October 2010 from multiple organ failure following hemorrhage from a femoral artery puncture sustained during coronary angiography on 21 October 2010. An Angio-Seal device was used to close the puncture site. She was discharged on 22 October with a small hematoma. By 25 October, she presented to her GP with a dramatically enlarged, extremely painful hematoma. The GP, Dr L., failed to refer her to hospital or contact the treating cardiologists, instead providing pain relief and antibiotics. The deceased collapsed on 27 October and was transferred to hospital in cardiac arrest, but her condition was not recoverable. The coroner found this death was preventable: referral to hospital on 25 October, or contact with the treating cardiologists in the days after the procedure, would almost certainly have saved her life. Critical failures included Dr L.'s failure to appreciate ongoing bleeding, lack of communication between hospital and GP, and inadequate discharge documentation.

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

Specialties

cardiologyemergency medicinegeneral practiceintensive care

Error types

diagnosticcommunicationsystemdelay

Drugs involved

prasugrelaspirinenoxaparinoxycodoneparacetamolcodeinecefalexinmetoclopramide

Clinical conditions

unstable anginacoronary artery diseaseretroperitoneal haemorrhagehypovolemic shockacute renal failurerespiratory failuremultiple organ failurebowel necrosisbowel ischaemia

Procedures

coronary angiographyfemoral artery catheterizationangio-seal vascular closure devicelaparotomybowel resection

Contributing factors

  • Angio-Seal device failed to maintain hemostasis
  • Failure of Dr L. to refer to hospital on 25 October
  • Failure of Dr L. to contact treating cardiologists despite extensive hematoma
  • Failure to identify ongoing arterial bleeding
  • Inadequate discharge summary from hospital
  • Lack of communication between hospital and general practitioner
  • Continuation of triple anticoagulation therapy post-procedure
  • Delay in seeking emergency care until 27 October

Coroner's recommendations

  1. All private and public hospitals performing angiograms should provide patients with a discharge summary containing a body diagram to mark hematoma extent, and documenting bleeding, pain levels, and medications at discharge
  2. Discharge summaries should encourage patients to retain and present the document to any doctor consulted for complications
  3. Discharge summaries should be provided electronically or as quickly as practicable to the patient's general practitioner
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