Coroner's Finding: PEDDEY Ross Dudley

63y · Male·pneumonia complicating anoxic brain injury, due to post-operative haemorrhage as a result of damage to the inferior epigastric artery

A 63-year-old man died from pneumonia complicating anoxic brain injury following a post-operative haemorrhage from the inferior epigastric artery during ileostomy closure surgery. The critical failure was a 2.5-hour delay (0530-1100 hours) in obtaining intravenous access and blood results that would have revealed a dropped haemoglobin from 130 to 75. Early signs of hypovolaemic shock (hypotension, tachycardia, sweating, dyspnoea) were not recognised as requiring emergency intervention. The junior registrar (Dr T.) inappropriately delegated care to a first-year intern (Dr K.) and left for clinic without follow-up. A CT pulmonary angiogram was pursued despite low clinical probability, delaying diagnosis until cardiac arrest occurred. Earlier recognition of haemorrhage, timely blood investigations, and appropriate escalation would likely have prevented death.