Inquest into the death of Anthony Barrett

54y · Male·Bowel ischaemia resulting from acute thrombosis of superior mesenteric artery and coeliac artery stents leading to occlusion of both stents

Anthony Barrett died from bowel ischaemia caused by acute thrombosis of his superior mesenteric artery and coeliac artery stents post-operatively. He had undergone left total knee replacement surgery at Fairfield Hospital on 28 September 2018. A vascular surgeon consultation had been explicitly requested by his orthopaedic surgeon but was not identified and actioned by any of the clinical staff involved in his pre-operative assessment, despite multiple opportunities to do so. The consultation request was documented on his admission form but was located in an unexpected position that clinicians did not routinely check. Had the vascular consultation occurred, imaging of his stents would have been performed, and appropriate consideration would have been given to his antiplatelet therapy and use of tranexamic acid. A vascular surgeon would likely have advised continuing clopidogrel and potentially avoiding tranexamic acid, or reconsidered the surgical approach. The coroner found that appropriate pre-operative management would have likely prevented stent occlusion and death.