Inquest into the Death of Evans
Deceased
Susan Denise Evans
Demographics
45y, female
Date of death
2004-11-25
Finding date
2008-02
Cause of death
Extensive retroperitoneal haemorrhage following bone marrow biopsy procedure with subsequent pulmonary thromboembolism and pulmonary infarction
AI-generated summary
Susan Denise Evans, a 45-year-old woman with complex medical history including neurofibromatosis type 1, essential thrombocytosis, prior cancers, and recent cerebral infarcts on warfarin, underwent bone marrow biopsy at Royal Perth Hospital on 23 November 2004 to investigate her thrombocytosis and exclude leukaemia. The procedure was appropriate and indicated. A retroperitoneal haemorrhage developed post-procedure—a known but rare complication. Despite appropriate recognition and initial conservative management with warfarin reversal and fluid resuscitation, the patient deteriorated suddenly on 24 November from pulmonary thromboembolism and died. The coroner found the death arose from natural causes. Key issues examined included the decision to perform biopsy whilst on warfarin (deemed appropriate given stroke risk), conservative management strategy (balancing bleeding against clotting risk), and monitoring. Recommendations addressed imaging-guided biopsy, expedited notification of abnormal blood results, and complete recording of observations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- Retroperitoneal haemorrhage as rare complication of bone marrow biopsy
- Patient on warfarin at time of procedure for stroke prevention
- Essential thrombocytosis with elevated clotting risk
- Dehydration contributing to pre-renal azotaemia
- Conservative management approach balancing anticoagulation needs against bleeding risk
- Pulmonary thromboembolism following retroperitoneal haemorrhage
Coroner's recommendations
- Where a bone marrow biopsy is to be carried out on a patient with complex and critical medical history, consideration should be given to its proceeding under imaging as is the case for many other procedures.
- Consideration be given to whether there needs to be an expedited method for notifying significantly abnormal blood test results to a medical member of the team responsible for a patient's care.
- All observations with respect to a patient be recorded and maintained with the patient's medical file. If observations are critical enough to be required four per hour, they are certainly important enough to be recorded. Similarly if observations are to be taken at all they should be recorded.
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