Finding into death of Warren Douglas Frazer

45y · Male·Complications of VATS procedure for locally advanced right upper lobe lung adenocarcinoma

A 45-year-old man died from complications following VATS lobectomy for lung adenocarcinoma. During initial surgery, the tumour invaded the T6 vertebral body. The surgeon, faced with incomplete tumour resection or vertebral body excision, chose to remove part of the vertebra. Post-operative spinal cord compression from haematoma required emergency laminectomy, but an 8-hour delay may have worsened neurological outcomes. Subsequent complications included tracheopleural fistula, recurrent fistula despite multiple repairs, and aerocephalus. The coroner found the surgeon's intraoperative decision reasonable given the clinical dilemma, but identified systemic gaps: inadequate pre-operative imaging to detect vertebral invasion, lack of intraoperative neurosurgical support at the primary hospital, delayed family communication, and informal inter-hospital transfer arrangements. Key lessons include obtaining advanced imaging when tumour location suggests vertebral involvement, establishing protocols for urgent neurosurgical consultation, formalising hospital transfer agreements, and improving family communication during prolonged surgery.