Finding into death of Ronald William Beaumont

74y · Male·Acute myocardial infarction complicated by multiple organ failure

Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual antiplatelet therapy (aspirin and ticagrelor) before surgery on 6 November 2023, the subsequent NSTEMI was not caused by thrombotic occlusion but by supply-demand mismatch from surgical stress, limiting medication error's causal contribution; (2) Inadequate pre-admission documentation and communication about anticoagulation management created confusion between orthopaedic and cardiology teams; (3) Post-operative wound complications required escalation and washout but earlier intervention unlikely to change outcome; (4) System failures in family communication at critical moments and post-death care pathway compliance. The coroner found no causal link between the medication error and death, emphasizing that routine surgical risks and outcome bias can obscure appropriate clinical processes.