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 haemorrhage from penetration of the femoral artery in association with coronary arteriosclerosis

AI-generated summary

A 60-year-old woman died from massive retroperitoneal bleeding following coronary angiography. An Angio-Seal device was used to close the femoral artery puncture but failed to maintain seal. Post-discharge, rapid haematoma expansion occurred. On day 4 post-procedure, she presented to her GP with severe pain and extensive bruising (10cm x 2cm) expanding across her abdomen. The GP did not hospitalise, refer to the cardiologist, or contact specialists—instead prescribing opioids. She remained untreated for 2 more days before presenting in cardiac arrest. Clinical lesson: expanding haematomas post-angiography require urgent specialist evaluation. Discharge summaries with documentation of haematoma size and anticoagulation details should be provided to GPs. Early escalation and communication between primary and specialist care could have prevented this death.

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

Specialties

cardiologygeneral practiceemergency medicinevascular surgeryintensive care

Error types

diagnosticcommunicationdelay

Drugs involved

prasugrelaspirinenoxaparinoxycodoneoxynormparacetamol/codeineclopidogrelcefalexinmetoclopramide

Clinical conditions

unstable anginaacute coronary syndromeretroperitoneal bleedinghaematomahypovolaemic shockmultiple organ failureacute renal failurebowel necrosisbowel ischaemiasepsiscoronary artery disease

Procedures

coronary angiographyfemoral artery punctureangio-seal vascular closure devicelaparotomybowel resection

Contributing factors

Failure of Angio-Seal device to maintain vascular closure
Possible high arterial puncture proximal to inguinal ligament
Continuation of anticoagulant therapy (prasugrel, aspirin, enoxaparin) post-procedure increasing bleeding risk
Failure of general practitioner to refer to hospital or contact cardiologist when presented with massive expanding haematoma
Inadequate discharge summary not provided to general practitioner
Delay in escalation of care from 25 October until 27 October
General practitioner misinterpretation of symptoms as infection rather than ongoing bleeding

Coroner's recommendations

All private and public hospitals at which angiograms are performed should provide patients with a discharge summary which would preferably contain a diagram of the body on which the extent of any haematoma could be marked and which would provide reliable information as to the extent of any bleeding, pain levels and medications at the time of discharge
Any such discharge summary given to a patient should encourage the patient to retain that document and take it to any doctor seen in the event of complications, such as ongoing bleeding
The discharge summary provided to the patient should also be provided electronically, or otherwise as quickly as practicable, to the patient's general practitioner

Full text

Official source Archived copy

Related cases from WA

WAhospital2025-02-21

Inquest into the Death of Fabian Alec COFFIN

51y · Male·complications of myocardial infarction in association with ischaemic heart disea…

A 51-year-old prisoner died from complications of myocardial infarction with ischaemic heart disease. He had multiple cardiovascular risk factors including type-2 diabetes, hypertension, high cholesterol, chronic kidney …

cardiologyemergency medicinediagnosticinsulin

WAmental health2024-07-19

Inquest into the Death of Phillip Benjamin VELTMAN

49y · Male·Unascertained - cardiac arrhythmia with terminal aspiration in an overweight man…

Phillip Veltman, 49, died of unascertained cause (likely cardiac arrhythmia with terminal aspiration) while an involuntary psychiatric patient at Bentley Mental Health Services. He presented to Royal Perth Hospital ED on…

psychiatryemergency medicinecommunicationsystemketamine

WAhome2024-04-04

Inquest into the Death of Child LT (Name Subject to Suppression Order)

11y · Male·unascertained

An 11-year-old child with Cornelia de Lange Syndrome and severe congenital heart disease died alone at home while his mother was intoxicated and unwell. He had complex care needs and was non-verbal. The Department of Com…

paediatricscardiologycommunicationsystemcocaine

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. Some material may have been redacted or restricted by court order or privacy requirements. 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 — report an inaccuracy here.