Inquest into the Death of Evans

45y · Female·Extensive retroperitoneal haemorrhage following bone marrow biopsy procedure with subsequent pulmonary thromboembolism and pulmonary infarction

Susan Denise Evans, a 45-year-old woman with complex medical history including neurofibromatosis type 1, essential thrombocytosis, prior cancers, and recent cerebral infarcts on warfarin, underwent bone marrow biopsy at Royal Perth Hospital on 23 November 2004 to investigate her thrombocytosis and exclude leukaemia. The procedure was appropriate and indicated. A retroperitoneal haemorrhage developed post-procedure—a known but rare complication. Despite appropriate recognition and initial conservative management with warfarin reversal and fluid resuscitation, the patient deteriorated suddenly on 24 November from pulmonary thromboembolism and died. The coroner found the death arose from natural causes. Key issues examined included the decision to perform biopsy whilst on warfarin (deemed appropriate given stroke risk), conservative management strategy (balancing bleeding against clotting risk), and monitoring. Recommendations addressed imaging-guided biopsy, expedited notification of abnormal blood results, and complete recording of observations.