Coroner's Finding: STEWART Margaret May

77y · Female·multi-organ failure due to massive transfusion-induced coagulopathy following retroperitoneal haemorrhage of unknown source

A 77-year-old woman died from multi-organ failure following massive transfusion-induced coagulopathy after a retroperitoneal haemorrhage of unknown origin post-knee replacement surgery. While Fragmin anticoagulation was appropriately prescribed, the critical issue was inadequate fresh frozen plasma replacement during massive transfusion. The anaesthetist fell behind the recommended 1:2 ratio of plasma to red cells because initial plasma units were unavailable as expected, and subsequent delays occurred obtaining more. Expert evidence established that maintaining appropriate plasma-to-red cell ratios during massive transfusion is essential to prevent coagulopathy, and that the patient would have had a 'reasonable chance' of survival had these ratios been maintained. Key lessons: establish robust transfusion protocols for massive haemorrhage, ensure real-time tracking of transfused products, and maintain appropriate coagulation support ratios to prevent iatrogenic coagulopathy.