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.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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