Finding into death of Bruce John Stubbs

59y · Male·Ruptured atherosclerotic abdominal aortic aneurysm (operated)

A 59-year-old man with a non-ruptured 8cm infrarenal abdominal aortic aneurysm (AAA) presenting with acute back pain was transferred from Bendigo to Royal Melbourne Hospital at 2.13am on 22 April 2008. Despite appropriate initial assessment identifying the AAA as requiring urgent repair, surgical staff deferred surgery twice—once at 3.20am and again at noon—delaying intervention for 34 hours. The patient was haemodynamically stable initially, but had ongoing pain managed with intravenous morphine. The coroner found that use of analgesia likely masked the clinical urgency and contributed to delay. The aneurysm ruptured overnight on 22-23 April. Emergency surgery on 23 April revealed rupture and perioperative complications led to cardiac arrest and death. The coroner found the surgical delays suboptimal; had surgery occurred promptly on admission, survival probability exceeded 80%. Key lessons: symptomatic large AAA with pain requires urgent same-day surgery; analgesia can be misleading; delays in high-risk presentations carry critical consequences.