AN INQUEST INTO THE DEATH OFJOHN BELL

71y · Male·cardiac arrest due to hyperkalemia due to acute on chronic renal failure, with recent laparotomy for ileostomy reversal being a significant contributing condition

John Bell, a 71-year-old man with history of bowel cancer, ischaemic heart disease, and chronic renal failure, underwent elective ileostomy reversal surgery. He died from cardiac arrest due to hyperkalemia and metabolic acidosis two days post-operatively. Expert renal review identified that his severely impaired kidney function and metabolic acidosis were not adequately investigated or managed preoperatively, and surgery should have been delayed pending renal consultation. Post-operatively, arterial blood gas measurements were not performed to assess acid-base status, and fluid management may have been excessive. While these management gaps may have influenced his clinical course, the expert could not definitively establish they directly caused death, as acute coronary event or occult sepsis could not be excluded. The hospital implemented remedial actions including establishment of a dedicated high-risk pre-admission clinic and improved inter-specialty communication.