Deceased
Edith Catherine BEE
Demographics
80y, female
Coroner
Deputy State Coroner Vicker
Date of death
2013-09-04
Finding date
2017-05-03
Cause of death
Gas embolism complicating surgical repair of an atherosclerotic aortic aneurysm in an elderly lady with multiple co-morbidities
AI-generated summary
An 80-year-old woman with multiple comorbidities (COPD, renal impairment, cardiac disease) underwent complex endoluminal repair of a thoracoabdominal aortic aneurysm at a private hospital. The procedure required use of CO₂ as an imaging agent due to her renal disease. The surgeon used a customised three-way tap delivery system instead of his preferred two-way system because the preferred equipment was unavailable. During the procedure, CO₂ was accidentally delivered directly into the patient's vascular system under pressure, likely when the delivery system was inadvertently disturbed. This caused fatal gas embolism. The coroner found the surgery decision appropriate given the patient's high rupture risk, but identified the use of a suboptimal delivery system as the critical error. The hospital and surgeon subsequently committed to using only TGA-approved CO₂ delivery systems.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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75y · Male·acute bronchopneumonia in a man with comorbidities
A 75-year-old sentenced prisoner died from acute bronchopneumonia with comorbidities. Mr Rice had extensive medical complexity including COPD, cardiac disease, peripheral vascular disease, and diabetes. He was appropriat…
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