Finding into death of Ruth Ann McKenna

62y · Female·Hypovolaemic and cardiogenic shock (hysterectomy) in the context of cardiomegaly, cirrhosis and coagulopathy

A 62-year-old woman with significant comorbidities (cirrhosis, cardiomegaly, thrombocytopenia, chronic kidney disease, COPD) died from hypovolaemic and cardiogenic shock during elective total laparoscopic hysterectomy for an endometrial polyp. Intraoperative blood loss was 2000-2500mls (far exceeding typical 150-200mls). Critical gaps included: surgery commenced without immediate platelet availability despite platelet count of 51 (lower limit acceptable); unrecognised right ventricular hypertrophy with probable pulmonary hypertension missed on pre-anaesthetic evaluation; inadequate pre-operative optimisation planning; no specialist cardiology or hepatology review despite severe liver disease; and lack of communication between pre-anaesthetic clinic and surgical team regarding investigation results. The cervical stenosis and complex adhesions encountered should have prompted consideration of conversion to open surgery earlier. Had platelets been available pre-operatively and cardiac complexity been recognised, the outcome may have differed.