McGuane, Shirley Fay - Non-inquest findings

84y · Female·Myocardial infarction

Shirley McGuane, 84, died from myocardial infarction following elective proctocolectomy. Post-operative care was deficient: chest pain on day 2 post-op with ECG showing atrial fibrillation and new right bundle-branch block was not investigated with troponin or blood tests despite this indicating possible myocardial infarction. Significant anaemia (Hb 72, down from 127) and signs of deterioration (oliguria, tachycardia, drowsiness) were not adequately escalated or investigated. No MERT call was made despite meeting criteria. Standard post-operative bloods were not performed. Documentation by the surgeon was minimal despite his shared responsibility for post-operative care. Clinical lessons: post-operative chest pain requires investigation; ECG abnormalities must trigger appropriate escalation and communication; deteriorating patients need formal escalation protocols; and surgeons must document their clinical assessments and decision-making.