Inquest into the Death of Arthur James BONNEY

Contributing factors

• administration of iodinated contrast to patient with eGFR <30 without appropriate risk mitigation
• failure to check eGFR on day of CT scan despite known chronic kidney disease
• continuation of nephrotoxic medications (spironolactone, perindopril, metformin) before and after contrast administration
• non-adherence to hospital's 2015 contrast-induced nephropathy prevention guidelines
• lack of pre-contrast and post-contrast hydration
• failure to perform 48-hour post-contrast creatinine testing
• reliance on outdated eGFR from early June 2015 that did not reflect patient's deteriorating renal function
• underlying severe ischaemic heart disease and cardiomyopathy

Coroner's recommendations

1. Implementation of same-day eGFR testing before contrast-enhanced CT scans (acknowledged as accomplished by FSH since 2016)
2. Adherence to risk-stratification protocols for patients with renal impairment undergoing contrast procedures
3. Consideration of non-contrast imaging alternatives in high-risk patients
4. Cessation of nephrotoxic medications before contrast administration in appropriate cases
5. Implementation of pre-contrast and post-contrast hydration protocols for at-risk patients
6. Mandatory 48-hour post-contrast creatinine testing to detect contrast-induced nephropathy
7. Enhanced processes for prisoner medical requests to ensure proper risk assessment and specialist review