Deceased
Henry Edwin Kerr
Demographics
86y, male
Date of death
2011-09-07
Finding date
2013-11-11
Cause of death
Acute Myocardial Ischaemia in an Elderly Man with Valvular and Ischaemic Heart Disease following Recent Operative Surgery
AI-generated summary
Henry Edwin Kerr, 86, died of acute myocardial ischaemia following left inguinal hernia surgery at Esperance District Hospital. He had significant cardiac history including valvular disease, ischaemic heart disease, and atrial fibrillation. After his first hernia repair in June 2011, he experienced chest pain on multiple occasions, but this was not clearly documented in a format accessible to the anaesthetist (Dr B.) conducting his second surgery in September 2011. The coroner found that had Dr B. been aware of the post-operative chest pain episodes, he would have referred the deceased to a cardiologist before proceeding with surgery. During the second procedure, the deceased suffered an acute myocardial infarction intraoperatively or shortly thereafter, leading to pulmonary oedema, respiratory failure, and cardiac arrest. The coroner found no evidence that different management—including earlier intubation or transfer to Perth—would have changed the outcome, but recommended GPs provide detailed medical histories to surgeons and hospitals in advance of elective surgery.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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