Finding into death of Nicola Deleo

91y · Male·Complications following cardiac arrest in the setting of anaesthetic induction during surgery for the treatment of small bowel obstruction due to a right inguinal hernia

A 91-year-old man with COPD, asthma, and previous cardiac arrest from suxamethonium died from complications following anaphylaxis to rocuronium during anaesthetic induction for emergency small bowel obstruction surgery. His GP records documented allergy to both suxamethonium and vecuronium (a non-depolarising blocker in the same class as rocuronium used), but this critical allergy information was not included in the hospital referral form sent 9 months earlier. The anaesthetic management and emergency surgery were clinically appropriate given life-threatening pathology. However, the absence of complete allergy information at the time of surgery represented a potential gap in care. The coroner recommended improving hospital referral templates to ensure allergies are consistently captured and communicated to reduce future iatrogenic harm.