Finding into death of Kum Yeo Bae

60y · Female·Penetrating injury of the descending thoracic aorta complicating spinal stabilization surgery for a T12 burst fracture

A 60-year-old woman died from a penetrating injury to the descending thoracic aorta sustained during spinal stabilisation surgery for a T12 burst fracture. During pedicle cannulation, the surgical awl fractured the left T11 pedicle and plunged superiorly, causing acute blood loss of 300-400ml and aortic laceration. Critical communication failure occurred: the surgeon believed blood loss was minimal, the anaesthetist understood it occurred over the entire procedure rather than acutely, and the senior surgeon was not informed of the acute loss. Haemodynamic stability was rapidly achieved with fluids, masking the severity of injury. The coroner found the decision to proceed with surgery was reasonable and the death was not preventable. Key learning: acute blood loss of this magnitude in this context warrants immediate senior consultation and consideration of thoracic surgical involvement.