Coroner's Finding: KRIVITCH Olga

81y · Female·hypovolaemic shock following bleeding from the site of a femoral angiogram

Olga Krivitch, 81-year-old woman, died from hypovolaemic shock caused by bleeding from her femoral angiogram puncture site. She was admitted for ischaemic leg and underwent unsuccessful thrombolytic therapy. Subsequently commenced on Heparin anticoagulation but therapeutic range took 38 hours to achieve, exposing her to over-anticoagulation. Critical failures included: haemoglobin levels not monitored on 25-26 January despite evidence of bleeding, resulting in massive undetected haemorrhage; over 4-hour delay between identifying haemoglobin of 54 and transfusion; and lack of experienced senior staff supervision. The Vascular Surgery Unit had no registrars on duty, only junior residents. With timely monitoring, blood transfusion and surgical intervention on 25-26 January, she likely would have survived. Key lessons: mandatory daily haemoglobin monitoring when anticoagulated; explicit instructions to junior staff; adequate senior supervision; Heparin protocols requiring haematology consultation when therapeutic range not established timely.