Multiple organ failure following haemorrhage from penetration of the femoral artery
AI-generated summary
A 60-year-old woman died from multiple organ failure caused by uncontrolled bleeding from an arterial puncture sustained during coronary angiography. Although the procedure itself was uncomplicated and an Angio-Seal device was inserted to seal the puncture, post-procedure bleeding continued. Critically, when the patient presented to her GP three days later with a massive, painful haematoma, the GP failed to recognize this as a medical emergency. She did not contact the treating cardiologist, did not refer to hospital, and incorrectly diagnosed the haematoma as infectious, prescribing only antibiotics and pain relief. Two days later, when the patient reached hospital in irreversible hypovolemic shock, emergency surgery revealed the bleeding site in the external iliac artery. The coroner found this death preventable: appropriate hospital referral or specialist consultation on day 3 would almost certainly have saved her life. Key lessons: post-angiography haematomas require urgent specialist assessment and discharge summaries with clear clinical indicators are essential.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Failure of general practitioner to recognize severity of ongoing bleeding on 25 October 2010
Absence of referral to hospital or treating cardiologist despite massive haematoma
Misdiagnosis of haematoma as infectious rather than ongoing arterial bleeding
Two-day delay in emergency intervention from presentation to GP
Poor discharge communication from hospital to general practitioner
Absence of detailed discharge summary with clinical indicators
Coroner's recommendations
All private and public hospitals at which angiograms are performed should provide patients with a discharge summary preferably containing a body diagram marking the extent of any haematoma, providing reliable information on extent of bleeding, pain levels and medications at discharge
Discharge summaries should encourage patients to retain the document and take it to any doctor seen in the event of complications such as ongoing bleeding
Discharge summaries should be provided electronically or otherwise as quickly as practicable to the patient's general practitioner
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