Finding into death of Alan John Trevor Deem

67y · Male·Intracranial haemorrhage complicating coronary artery bypass graft surgery following right coronary artery dissection sustained in percutaneous coronary intervention for the treatment of ischaemic heart disease

A 67-year-old man died from intracranial haemorrhage following coronary artery bypass graft surgery. He had suffered a right coronary artery dissection during percutaneous coronary intervention at Sunshine Hospital and was transferred to Royal Melbourne Hospital for cardiothoracic surgery. A significant delay occurred between detection of the dissection (9:12 AM) and referral (approximately 12:45 PM, transfer at 3 PM). Critical deficiencies in medical record-keeping at both hospitals prevented determination of whether the delay contributed to death. The coroner found suboptimal inter-hospital transfer procedures, lack of contemporaneous documentation of the referral discussion, and breach of the receiving hospital's own record-keeping policies. While medical management was deemed reasonable, systemic failures in documentation and communication protocols were identified as preventable factors in future similar cases.