Chan findingsfinal26oct2010

77y · Female·Intracranial haemorrhage suffered during the course of neurosurgery

Oi Fong Chan, a 77-year-old woman, underwent endoscopic trans-nasal pituitary surgery at Concord Hospital on 8 December 2006 to remove a benign pituitary adenoma. During the operation, the surgical team inadvertently encountered an aberrant (abnormally positioned) blood vessel and the surgical field began bleeding profusely. Despite appropriate use of multiple haemostatic techniques including packing, surgicel, thrombin, and gelfoam, the bleeding continued on the other side of the packing, causing severe intracranial and intraventricular haemorrhage. Mrs Chan died on 9 December 2006 from raised intracranial pressure and brain stem compression. Investigation revealed no surgical error or misnavigation—the complication resulted from natural anatomical variation: an aberrant vessel and the patient's slightly lower brain position. The coroner found this an unavoidable tragedy. The surgical team demonstrated appropriate skill and management. Recommendations addressed surgical teamwork: formal pre-operative team briefings and introductions by name and role, with WHO checklist adaptation for NSW.