Inquest into the death of Sandra Cree

71y · Female·Ruptured abdominal aortic aneurysm, with coronary artery atherosclerosis contributing

Sandra Cree, a 71-year-old woman, died from a ruptured abdominal aortic aneurysm (AAA) after undergoing an elective endovascular repair procedure in Brisbane. She presented to a remote hospital (Lightning Ridge Multi-Purpose Service) in early April 2016 with classic symptoms of AAA rupture: hypotension, shock, abdominal and back pain. Critical clinical lessons emerged: (1) Dr K. at Lightning Ridge made the correct diagnosis but lacked access to prior medical records due to password protection issues and inadequate attempts to contact the referring surgeon; (2) the State Retrieval Consultant (Dr N.) became aware of the likely diagnosis but failed to clearly communicate it to either the treating doctor or retrieving team, instead becoming dismissive of the local doctor; (3) the retrieving doctor (Dr J.) performed an inadequate FAST ultrasound, over-relied on a negative result, and incorrectly prioritized sepsis as the working diagnosis; (4) critically, there was no formal handover between consecutive State Retrieval Consultants, and the receiving Dubbo hospital was not pre-alerted about the suspected aneurysm rupture. While transfer to a tertiary hospital may not have changed the outcome, early recognition and appropriate triage to a facility capable of emergency vascular surgery could have offered marginal survival benefit.