Finding into death of Ann Leah Jones

87y · Female·Pulmonary artery rupture complicating pulmonary artery catheter insertion in a woman with severe ischaemic heart disease

Mrs Jones, an 87-year-old woman with severe ischaemic heart disease, died from pulmonary artery rupture during elective off-pump coronary artery bypass surgery. A Swan-Ganz pulmonary artery catheter (PAC) was inserted pre-operatively for haemodynamic monitoring. Approximately 45 minutes later, at anaesthetic induction, moderate blood was observed in her oral cavity—a known clinical sign of PAC-related pulmonary artery injury. Despite intubation and resuscitation attempts, she developed massive pulmonary haemorrhage, hypoxia, and cardiac arrest. An intra-aortic balloon pump inserted during resuscitation caused secondary aortic rupture in her severely atherosclerotic aorta. The coroner found the medical care reasonable but noted institutional improvements: delaying PAC balloon flotation until after sternotomy, delaying anaesthesia induction until surgeon arrival, and improving staff awareness of subtle haemodynamic parameter changes.