Finding into death of Josip Dobrovoljski

62y · Male·Global cerebral ischaemia secondary to intra-operative hypotension following the administration of protamine

A 62-year-old man died from global cerebral ischaemia following intra-operative hypotension after protamine administration during a cardiac ablation procedure. He had suffered a severe hypotensive reaction to protamine 8 days earlier during coronary artery bypass surgery, which was inadequately documented and not communicated to the ablation team. Critical failures included: incomplete anaesthetic charting of the initial protamine reaction, absent handover communication between ICU and EP laboratory staff, no completion of Surgical Safety Checklist or Time Out before the ablation, and the red alert bracelet being covered by surgical drapes. While the patient was in a perilous cardiac condition, knowledge of his previous protamine reaction might have prompted reconsideration of its necessity or administration method, potentially preventing death. The case emphasises the importance of accurate documentation and structured handover in complex critically ill patients.