Inquest Into The Circumstances Surrounding The Death Of Alex Nicholas Mersiades

3y · Male·cerebral oedema which caused coning at the base of the brain, caused by post-operative hyponatraemia

A 3-year-old boy died from cerebral oedema caused by post-operative hyponatraemia following scoliosis correction surgery. The operation was successful, but severe hyponatraemia developed in the early hours of 24 April 1988, causing cerebral oedema and brain herniation. Death occurred 25 April 1988. The coroner found the death was caused by failure to monitor serum sodium levels post-operatively. Despite extensive published literature on hyponatraemia as a post-operative complication (particularly after scoliosis surgery in children), the surgical and anaesthetic teams were unaware of this risk. The coroner recommended that future scoliosis operations should include daily serum sodium monitoring with appropriate corrections. Once the seizure occurred, brain damage was irreversible.