Inquest into the Death of Aslett, Wendy May

60y · Female·Multiple organ failure following hemorrhage from penetration of the femoral artery

Wendy May Aslett, aged 60, died on 29 October 2010 from multiple organ failure following hemorrhage from a femoral artery puncture sustained during coronary angiography on 21 October 2010. An Angio-Seal device was used to close the puncture site. She was discharged on 22 October with a small hematoma. By 25 October, she presented to her GP with a dramatically enlarged, extremely painful hematoma. The GP, Dr L., failed to refer her to hospital or contact the treating cardiologists, instead providing pain relief and antibiotics. The deceased collapsed on 27 October and was transferred to hospital in cardiac arrest, but her condition was not recoverable. The coroner found this death was preventable: referral to hospital on 25 October, or contact with the treating cardiologists in the days after the procedure, would almost certainly have saved her life. Critical failures included Dr L.'s failure to appreciate ongoing bleeding, lack of communication between hospital and GP, and inadequate discharge documentation.