Inquest into the Death of Kerr, William
Deceased
Kerr, William
Demographics
86y, male
Date of death
2011-09-07
Finding date
2013
Cause of death
Acute Myocardial Ischaemia in an Elderly Man with Valvular and Ischaemic Heart Disease following Recent Operative Surgery
AI-generated summary
An 86-year-old man with atrial fibrillation, ischaemic heart disease and hypertension underwent left inguinal hernia repair under general anaesthesia at a regional hospital. He experienced a small acute myocardial infarction during or immediately after surgery, which remained undiagnosed in theatre despite intraoperative hypotension. Post-operatively, he developed acute respiratory distress attributed to bronchospasm and later aspiration, treated initially with bronchodilators and only intubated after oxygen saturations dropped sharply. He subsequently developed cardiogenic pulmonary oedema and ultimately died from heart failure. The coroner found the post-operative management appropriate given the clinical picture presented at the time, but noted that pre-operative assessment failed to capture significant post-operative chest pain from his previous hernia surgery three months earlier. Had the anaesthetist known of this prior cardiac event, cardiology review would have been sought before proceeding.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Significant previous post-operative chest pain from June 2011 hernia repair not communicated to anaesthetist or pre-admission nurse
- Intraoperative myocardial infarction occurring during or immediately after hernia repair
- Absence of cardiologist review pre-operatively despite ischaemic heart disease and recent cardiac events
- Post-operative hypovolaemia or anaesthetic effects masking early cardiac failure
- Delay in recognition that symptoms represented cardiogenic shock rather than simple bronchospasm or aspiration
Coroner's recommendations
- GPs referring a patient for surgery should provide a detailed medical history to the surgeon and hospital, to be distributed in advance to the anaesthetist and pre-admission practitioner
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