Inquest into the death of John Gibson

63y · Male·Right cerebral infarction caused by infusion of medication via central venous line inadvertently inserted into the carotid artery

A 63-year-old man with COPD, liver cirrhosis and alcohol dependence underwent emergency hemicolectomy for caecal volvulus. Post-operatively he developed respiratory depression, hypernatremia and alcohol withdrawal requiring benzodiazepines and BiPap support. A central venous line was inserted for medication access prior to transfer to ICU. The line was inadvertently placed in the carotid artery rather than jugular vein. Although this was recognised 36 hours later, medications including dextrose had been infused via the arterial line, causing right cerebral infarction. The clinician relied on absence of pulsatile flow and blood colour to confirm placement but failed to perform manometry, transduction, or blood gas assessment despite hypotension making these bedside checks unreliable. Chest X-ray alone cannot confirm venous placement. Best practice mandates formal confirmation of venous placement before use.