Mr DAC - Non-inquest findings

51y · Male·Sepsis due to or as a consequence of right lower limb necrotising fasciitis due to or as a consequence of right inguinal femoral artery pseudo-aneurysm, coronary atherosclerosis (stent insertion), and ischaemic heart disease

A 51-year-old man with metastatic renal cell carcinoma died from sepsis following necrotising fasciitis of the lower limb, which developed after a pseudo-aneurysm complication from coronary angiography. Key clinical lessons: (1) inadequate pre-procedure assessment in a complex patient with multiple comorbidities and anticoagulation; (2) failure to recognise and act on post-procedure bleeding complications—a competent cardiologist should have performed urgent ultrasound imaging on 11 May to exclude pseudo-aneurysm, which could have been treated with thrombin injection; (3) lack of communication between teams regarding palliative status and prognosis; (4) selection of femoral rather than radial approach despite obesity and bleeding risk. The post-operative bleeding management was deemed negligent and below standard of care. Early diagnosis and thrombin injection would almost certainly have prevented the catastrophic outcome.