Inquest into the Death of Helen Christine MacFARLAINE

52y · Female·intracerebral haemorrhage in a lady with underlying cerebrovascular disease and hypertension following right carotid artery endarterectomy

A 52-year-old woman underwent right carotid endarterectomy for high-grade stenosis. Post-operatively she developed escalating blood pressure readings (160–220 mmHg), headaches, nausea, agitation, and abnormal behaviour over 6–7 April. Despite a critical BP spike of 220/110 and multiple concerning observations documented by nursing staff, the findings of nursing staff regarding blood pressure parameters and the patient's clinical deterioration were not properly escalated or documented. The patient was discharged on morning of 8 April based on incomplete clinical summaries ('observations stable') despite elevated BP readings and preceding day's complications. She suffered catastrophic intracranial haemorrhage the next morning, attributed to likely hyperperfusion syndrome. Key failures included inadequate documentation of observations, lack of communication regarding blood pressure concerns between nursing/medical staff, failure to recognize post-operative blood pressure parameters (100–160 mmHg systolic), and insufficient escalation despite high-risk findings.