Clarke,heidimaree1223 09 findings&recommendations

Female·massive intra-abdominal haemorrhage caused by injuries to her right common iliac artery and vein during laparoscopic salpingectomy for ectopic pregnancy

Heidi Maree Clarke, a patient undergoing treatment for ectopic pregnancy, died on 30 April 2009 from massive intra-abdominal haemorrhage caused by injuries to her right common iliac artery and vein sustained during laparoscopic salpingectomy at Wagga Wagga Base Hospital. The surgical procedure resulted in vascular injury leading to fatal bleeding. The inquest examined the circumstances surrounding the procedure and heard evidence from multiple clinicians and hospital representatives. The coroner made three key recommendations: undertaking a feasibility study on electronic recording of surgical procedures in NSW Health facilities, adoption of family communication checklists in operating rooms as proposed by Ms Tracy Collins, and review of current on-call procedures for clinicians within the health network. These recommendations indicate systemic improvements in surgical safety, procedural documentation, and family communication could prevent similar deaths in future.