Inquest into the death of Joshua Szczudlo

33y · Male·Fatal cardiac arrhythmia, secondary to acute kidney injury

Joshua Szczudlo, a 33-year-old man with morbid obesity (estimated weight 195kg), underwent shoulder fracture repair surgery on 17 March 2016 at Liverpool Hospital. He died 38 hours post-operatively from a fatal cardiac arrhythmia secondary to acute kidney injury with severe hyperkalaemia. Pre-operative assessment identified significant risks (obesity, hypertension, probable sleep apnoea) but surgery proceeded with appropriate anaesthetic management. Post-operative care occurred on a general orthopaedic ward rather than ICU. Key shortcomings included inconsistent supplemental oxygen delivery despite morphine PCA use, and inadequate recording of urine output—both potentially significant in a high-risk patient. While the coroner found no deficiency in care that directly caused death, the case highlights the need for bariatric-specific protocols, reliable weight measurement, and continuous respiratory monitoring for obese post-operative patients on opioids.