Finding into death of Hugh Peter Bourke

68y · Male·Hypoxic brain injury and ischaemic heart disease

Hugh Peter Bourke, a 68-year-old man with a history of myocardial infarction, atrial fibrillation, and recent abdominal surgery, suffered a cardiac arrest at home on 6 January 2011. He had undergone cholecystectomy in December 2010, complicated by cholecystoduodenal fistula, followed by endoscopic retrograde cholangiopancreatography and stent placement on 31 December 2010. He was discharged on antibiotics four days before his arrest. The coroner found no evidence of preventable error. The clinical lesson emphasises appropriate post-operative follow-up and medication management in elderly patients with cardiac risk factors, particularly those undergoing complex biliary interventions. Documentation of clinical decision-making regarding continued antibiotic therapy and cardiac monitoring post-discharge would have been relevant.