Coroner's Finding: FALANGA Salvatore

77y · Male·complications of haemothorax and hypotension following drainage of pleural effusion, post coronary by-pass surgery, in the setting of longstanding multi-organ disease related to diabetes, hypertension, hyperlipidaemia and previous smoking history

77-year-old male died from complications of haemothorax and hypotension following drainage of pleural effusion post-coronary bypass surgery, in the setting of pre-existing renal impairment and diabetes. During pleural tap procedures performed 7 February 2003, trauma to intercostal vessels led to bleeding into the pleural cavity. Critical period was early morning 8 February when hypotension and deteriorating renal function occurred. Key clinical lessons: (1) recognition of hypovolaemic shock required more aggressive fluid resuscitation earlier; (2) senior clinician review warranted overnight given complexity and high-risk comorbidities; (3) ICU consultation should have occurred during weekend deterioration; (4) central venous pressure monitoring would have guided fluid management more accurately; (5) consultant cardiologist on-call should have recognised need for escalation rather than ward-based management alone. Although more aggressive intervention may not have altered outcome, it would have maximised chances of recovery.