Inquest into the Death of Helen Christine MacFARLAINE
Deceased
Helen Christine MacFARLAINE
Demographics
52y, female
Date of death
2012-04-12
Finding date
2015-08-12
Cause of death
intracerebral haemorrhage in a lady with underlying cerebrovascular disease and hypertension following right carotid artery endarterectomy
AI-generated summary
A 52-year-old woman underwent right carotid endarterectomy for high-grade stenosis. Post-operatively she developed escalating blood pressure readings (160–220 mmHg), headaches, nausea, agitation, and abnormal behaviour over 6–7 April. Despite a critical BP spike of 220/110 and multiple concerning observations documented by nursing staff, the findings of nursing staff regarding blood pressure parameters and the patient's clinical deterioration were not properly escalated or documented. The patient was discharged on morning of 8 April based on incomplete clinical summaries ('observations stable') despite elevated BP readings and preceding day's complications. She suffered catastrophic intracranial haemorrhage the next morning, attributed to likely hyperperfusion syndrome. Key failures included inadequate documentation of observations, lack of communication regarding blood pressure concerns between nursing/medical staff, failure to recognize post-operative blood pressure parameters (100–160 mmHg systolic), and insufficient escalation despite high-risk findings.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to monitor and document escalating blood pressure readings in immediate post-operative period
- inadequate or absent documentation of nursing observations and clinical decision-making
- failure to escalate concerning blood pressure reading of 220 mmHg to medical staff in timely manner
- failure to communicate post-operative blood pressure parameters (100–160 mmHg systolic) to ward staff
- attribution of patient's symptoms (agitation, headache, confusion) to psychological causes rather than investigating organic causes
- incomplete or inaccurate handover of clinical information to discharging physician
- discharge decision based on summary that observations were 'stable' when they were not
- failure to recognize headache and elevating blood pressure as warning signs of hyperperfusion syndrome
- lack of correlation between observation charts and medical documentation
- inadequate nursing notes regarding high blood pressure reading and actions taken
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