Inquest into the Death of Kerr, William

86y · Male·Acute Myocardial Ischaemia in an Elderly Man with Valvular and Ischaemic Heart Disease following Recent Operative Surgery

An 86-year-old man with atrial fibrillation, ischaemic heart disease and hypertension underwent left inguinal hernia repair under general anaesthesia at a regional hospital. He experienced a small acute myocardial infarction during or immediately after surgery, which remained undiagnosed in theatre despite intraoperative hypotension. Post-operatively, he developed acute respiratory distress attributed to bronchospasm and later aspiration, treated initially with bronchodilators and only intubated after oxygen saturations dropped sharply. He subsequently developed cardiogenic pulmonary oedema and ultimately died from heart failure. The coroner found the post-operative management appropriate given the clinical picture presented at the time, but noted that pre-operative assessment failed to capture significant post-operative chest pain from his previous hernia surgery three months earlier. Had the anaesthetist known of this prior cardiac event, cardiology review would have been sought before proceeding.