Finding into death of Susan Mary Royals

74y · Female·Complications of carotid artery injury from central line insertion in the setting of surgery for metastatic carcinoma

Susan Royals, a 74-year-old woman with metastatic colon cancer, died from complications of carotid artery injury sustained during central venous catheter (CVC) insertion as part of a Whipple procedure and hemicolectomy. The CVC was inadvertently placed in the right carotid artery, leading to right cerebral hemisphere watershed ischaemia despite surgical repair. She subsequently developed multi-organ failure and died. While arterial puncture is a recognised 6-9% complication of CVC insertion, ultrasound guidance—now considered gold standard—was used but not documented. Northern Health implemented comprehensive remedial actions including mandatory safety steps for CVC placement confirmation, standardised documentation, requirement for ultrasound-guided insertion, and multi-disciplinary intra-operative planning. The coroner commended these proactive improvements and made no adverse findings against clinicians.