Coroner's Finding: Whitney, Margaret Ann

81y · Female·hypovolemic shock due to haemorrhage during orthopaedic repair of a femur fracture

Margaret Ann Whitney, an 81-year-old woman with vascular dementia, died from hypovolemic shock due to haemorrhage during orthopaedic surgery for a femoral fracture sustained in a fall at her nursing home. She had been subject to guardianship orders and was living in aged care. Surgery was appropriately delayed to allow anticoagulation (apixaban) to wear off. The coroner found that medical and nursing care was of good standard throughout. Ms Whitney had pre-existing poor physiological reserve (anaemia, aortic calcification) which contributed to inability to tolerate significant intraoperative bleeding. The coronial medical consultant confirmed appropriate management and that post-mortem significant contributing factors were not apparent on clinical assessment. No clinical errors or preventable factors were identified.