coronial health care related deaths dr don buchanan forensic medical officer queensland
TRANSCRIPT
![Page 1: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/1.jpg)
CORONIAL HEALTH CARE RELATED DEATHS
Dr Don Buchanan
Forensic Medical Officer
Queensland
![Page 2: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/2.jpg)
PURPOSE
To help prevent deaths from similar causes happening in the future
![Page 3: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/3.jpg)
REPORTABLE DEATHS
• “Reportable Deaths” must be reported to –– Coroner– Police officer
• Death in custody only reported to State Coroner or Deputy State Coroner
• If death reported to police officer because a death certificate has not or is likely not to be issued, police officer can wait until satisfied this is or will be the case
![Page 4: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/4.jpg)
CRITERIA FOR REPORTABLE DEATHS
Geographical
Category of death
![Page 5: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/5.jpg)
GEOGRAPHICAL
Death happened in Qld.
Death happened elsewhere but– Body of deceased in Qld, or– At time of death person ordinarily lived in Qld, or– At time of death person was on a journey to or from
somewhere in Qld, or– Death caused by an event that happened in Qld
However death outside Qld, not reportable if it has already been reported to a non-Qld coroner.
If the death occurred outside Australia, coroner not to investigate unless directed by the Minister
![Page 6: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/6.jpg)
NATURE OF DEATH
• Person unknown• Violent or otherwise unnatural death• Suspicious circumstances• Death a health care related death• Death certificate not issued and not likely
to be issued• Death in care• Death in custody• Police operations
![Page 7: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/7.jpg)
VIOLENT OR UNNATURAL DEATHS
Violent generally clear
Unnatural traditionally – accident, suicide or homicide
Three broad categories of unnatural deaths
– Effects of chemicals eg alcohol, drugs and poisons
– Deprivation of air, food, water such as asphyxia, drowning, dehydration, starvation
– Physical factors such as trauma, cold, heat, fire, electricity, radiation
![Page 8: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/8.jpg)
?UNNATURAL DEATHS
Doctrine of Double Effect– Intention/Foresight Distinction
Withholding/Withdrawal of Medical Treatment– Act/Omission Distinction (Re: B; Bland’s case)
![Page 9: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/9.jpg)
SUSPICIOUS DEATHS
Initial cause of death uncertain
Concern about surrounding circumstances
![Page 10: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/10.jpg)
HEALTH CARE RELATED DEATH
“Health care” means a health procedure or any care, treatment, advice, service or good provided for the benefit of human health
![Page 11: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/11.jpg)
HEALTH CARE RELATED DEATH
“Health procedure” means a dental, surgical or other health related procedure, including for example the administration of an anaesthetic, analgesic, sedative or other drug
![Page 12: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/12.jpg)
HEALTH CARE RELATED DEATH
Death under this category reportable if –
(1) Health care likely caused or contributed to death;
AND
(2) Immediately before health care provided, independent person would not have reasonably expected the health care would cause/contribute to the death
![Page 13: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/13.jpg)
HEALTH CARE RELATED DEATH
Death under this category reportable if -
(1) Failure to provide health care likely caused or contributed to death;
AND
(2) When health care sought, independent person would not have reasonably expected the failure to provide the health care that would cause/contribute to the death
![Page 14: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/14.jpg)
HEALTH CARE RELATED DEATH
Independent person is to have regard to all relevant matters including –
• Deceased’s state of health as it was thought to be when health care begun or sought;
• Clinically accepted range of risk associated with the health care;
• Circumstances in which health care was provided or sought.
![Page 15: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/15.jpg)
HEALTH CARE RELATED DEATH
Ask TWO basic questions
1. Did the health care cause or contribute to the death?
2. Was the death from the health care not reasonably expected?
![Page 16: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/16.jpg)
HEALTH CARE RELATED DEATH
1. Did the health care cause or contribute to the death?
• Would the person have died at about the same time without the health care? Y/N
• Did the death result directly from the underlying disease or injury? Y/N
• Was the health care carried out with all reasonable care and skill? Y/N
If all answered “yes”, then procedure did not cause or contribute to the death
![Page 17: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/17.jpg)
HEALTH CARE RELATED DEATH
2. Was the death not reasonably expected?
• Before health care was provided, was the patient’s condition such that the death was foreseen as more likely than not to occur? Y/N
• Was the person told that death was foreseen as more likely than not to occur? Y/N
• Was the decision to provide the health care reasonable given the person’s condition, including their quality of life, if the health care was not provided? Y/N
If all answered “yes”, then death was reasonably expected
![Page 18: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/18.jpg)
HEALTH CARE RELATED DEATH
For failure cases ask two basic questions -
1. Did the failure to provide health care cause or contribute to the death?
2. Was the failure to provide health care that caused/contributed to the death not reasonably expected?
![Page 19: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/19.jpg)
CORONER CAN CEASE INVESTIGATING A REPORTABLE DEATH
• If a death is reportable but coroner considers no autopsy and no further investigation required
• Can authorise doctor to issue routine (non-coronial) cause of death certificate
• Treating doctor must complete a Form 1A with summary of deceased’s last illness attached
![Page 20: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/20.jpg)
ROLE OF CLINICAL FORENSIC MEDICAL OFFICER
Review deaths pursuant to a Form 1A and advise if reportable or not reportable;
- if reportable, advise whether autopsy and further investigation is warranted (or not).
Where autopsy ordered and further investigation commenced, advise on the clinical and/or toxicological aspects of the death
![Page 21: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/21.jpg)
Case 1
• 56 year old woman• Admitted for biopsy cerebral tumour• Frozen section – anaplastic malignancy
(severely abnormal cells)• 6 hours post op - decreased LOC, intubated,
ventilated• Urgent CT - haemorrhage into tumour• Decision in consultation with family (in view of
histology) was not to operate again – brain death
![Page 22: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/22.jpg)
Case 1
Form 1A to the coroner
Interim Death Certificate stated -• 1(a) Cerebral Oedema• 1(b) Right Anaplastic Cerebral Tumour
Reportable or Not Reportable?
![Page 23: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/23.jpg)
Case 1
1. Did the health care cause or contribute to the death?
• Would the person have died at about the same time without the health care? Ans: N
• Did the death result directly from the underlying disease or injury? Ans: N
• Was the health care carried out with all reasonable care and skill? Ans: Y
Hence health care caused/contributed to the death
![Page 24: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/24.jpg)
Case 1
2. Was the death from the health care not reasonably expected?
• Before the health care was provided, was the patient’s condition such that the death was foreseen as more likely than not to occur? Ans: N
• Was the person told that death was foreseen as more likely than not to occur? Ans: N
• Was the decision to provide the health care reasonable given the person’s condition, including their quality of life, if the health care was not provided? Ans: Y
Hence the death was not reasonably expected.
![Page 25: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/25.jpg)
Case 1
Suggested Death Certificate• 1(a) Cerebral Oedema• 1(b) Haemorrhage into Anaplastic
Cerebral Tumour• 1(c) Biopsy of Anaplastic Cerebral
Tumour
![Page 26: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/26.jpg)
Case 2
• 66 year old Male• PH – COPD, AVR, carcinoma colon• Admitted for right hemicolectomy• Post op – ICU – wound infection - sepsis –
settled after 10 days sufficient for discharge to ward
• CVL required replacement – At 1800 hours a R subclavian approach – check CXR ordered;
• 0200 hours ward call ATSP re SOB - ?CCF ?COPD – given diuretics, bronchodilators – minimal effect – then arrests and dies
![Page 27: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/27.jpg)
Case 2
Form 1A to the coroner
Interim Cause of death certificate stated -• 1(a). Respiratory Failure• 1(b). Acute exacerbation COPD
• 2. Carcinoma colon
Reportable or Not Reportable?
![Page 28: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/28.jpg)
Case 2
• Copy of medical notes received• No documentation made at the time when
central line was replaced – written in retrospect
• No note made at any time that CXR was seen• CXR showed R pneumothorax• A pneumothorax not considered by doctors
treating him for the acute SOB episode prior to death (supported by interim Cause of Death Certificate)
![Page 29: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/29.jpg)
Case 2
1. Did the health care cause or contribute to the death?
• Would the person have died at about the same time without the health care? Ans: N
• Did the death result directly from the underlying disease or injury? Ans: N
• Was the health care carried out with all reasonable care and skill? Ans: ?Y
Hence the health care (ie replacement of central line) caused/contributed to the death.
![Page 30: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/30.jpg)
Case 2
2. Was the death from the health care not reasonably expected?
• Before the health care was provided, was the patient’s condition such that the death was foreseen as more likely than not to occur? Ans: N
• Was the person told that death was foreseen as more likely than not to occur? Ans: N
• Was the decision to provide the health care reasonable given the person’s condition, including their quality of life, if the health care was not provided? Ans: Y
Hence the death from the health care was not reasonably expected.
![Page 31: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/31.jpg)
Case 2
Suggested Cause of Death Certificate• 1(a) Respiratory failure• 1(b) Right sided pneumothorax• 1(c) Insertion right subclavian central venous
line• 2. carcinoma colon, chronic obstructive
pulmonary disease
![Page 32: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/32.jpg)
Case 3
• 80 year old male• PH – CCF, COPD, OA• PC – sudden onset severe epigastric pain previous 2
hours; rigid abdomen, free air in abdomen; febrile• Laparotomy – perforated DU; successfully repaired;
sent to ICU• Post op – cardiogenic shock treated with inotropes,
settles over 5 days; extubated; sent to ward• Next day spikes fever, AF, hypotensive episode• Resuscitated; re-admitted to ICU diagnosis sepsis;• Despite inotropic support and IV antibiotics - dies
![Page 33: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/33.jpg)
Case 3
• Form 1A to coroner• Interim death certificate states –• 1(a) Multi organ failure• 1(b) Abdominal sepsis• 1(c) Perforated duodenal ulcer• 2. Congestive Cardiac Failure, COPD
Reportable or Not reportable?
![Page 34: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/34.jpg)
Case 3
1. Did the health care cause or contribute to the death?
• Would the person have died at about the same time without the health care? Ans: Y
• Did the death result directly from the underlying disease or injury? Ans: Y
• Was the health care carried out with all reasonable care and skill? Ans: Y
Hence the health care did not cause/contribute to the death.
![Page 35: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/35.jpg)
Case 4
• 59 year old man presented with chest pain to local country hospital one evening
• Discharged next morning pain free• Advised to see LMO in 2 days for follow up• LMO diagnosed chest wall pain• Found dead next morning – police called• LMO prepared to complete death certificate
as MI being the cause of death given his pain and past medical history
![Page 36: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/36.jpg)
Case 4
Form 1A to coroner
Interim death certificate stated –
1(a) Myocardial Infarction
![Page 37: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/37.jpg)
Case 4
Hospital Medical Record• Pain came on after lifting and was 9/10 severity• Initially was sharp then dull not associated with
nausea, cough, fever or palpitations• No PMH, FH recorded• Smoker, on no medication• Examination records normal heart sounds and
the chest was clear• Troponin was negative• No CXR or other test
![Page 38: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/38.jpg)
Case 4
Hospital Medical Record• But CXR report done 12 months earlier
documenting cardiomegaly• Discharged pain free next morning with
advice for follow up with LMO• Follow up recommended exercise stress test,
cholesterol test and maybe CXR
![Page 39: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/39.jpg)
Case 4
LMO Medical Notes
• Seen 2 days later with history of episodic but continuing pain
• Notes document patient had family history of heart disease
• History of borderline hypertension, raised cholesterol, and indeed was a smoker
• Examination consisted of sternal palpation - was tender - Nil other examination recorded
• Chest wall pain diagnosed
• Given NSAIDs
![Page 40: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/40.jpg)
Case 4
LMO Medical Notes• An entry noted he had had a CT Angiogram of
thoracic aorta at a provincial hospital 18 months earlier after being struck by a car
• GP was requested to provide her copy of this report
• Report documented a dilated aortic root 5.5cm diameter, longstanding, and report recommended further investigation with ultrasound
![Page 41: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/41.jpg)
Case 4
1. Did the failure to provide health care cause or contribute to the death?
• Would the person have likely died if the health care had been provided? Ans: N
• Was the underlying disease or injury such that it was not amenable to the health care that was sought? Ans: N
• Was the health care that was actually provided carried out with all reasonable care and skill? Ans: N
Hence the failure to provide health care caused/contributed to the death.
![Page 42: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/42.jpg)
Case 4
2. Was the failure to provide health care that caused/contributed to the death not reasonably expected?
• When the health care was sought, was the patient’s condition such that the death was foreseen as more likely than not to occur? Ans: N
• Was the person told that death was foreseen as more likely than not to occur? Ans: N
• Was the decision not to provide the health care reasonable given the person’s condition at the time? Ans: N
Hence the death from the failure to provide health care was not reasonably expected.
![Page 43: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/43.jpg)
Case 4
• Reportable• Given the information provided, further
examination recommended• Hence interim death certificate not accepted
![Page 44: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/44.jpg)
Case 4
Autopsy revealed a type A aortic dissection (dissecting aortic aneurysm) with cardiac tamponade (600ml)
![Page 45: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/45.jpg)
Case 4
Advice• Dangers of use of retrospectocope• Dissecting aortic aneurysm difficult to
diagnose• But inadequate history taking, physical
examination, investigation, limited the chance of diagnosis
• And there were hints
![Page 46: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/46.jpg)
THE END
![Page 47: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/47.jpg)
Case 5
45 year old woman carcinoma rectum• Routine admission for anterior resection and loop
ileostomy• No significant PMH; on no medications• Pre-op PR 84; BP 140/85; Hb 120; Plts 386
Operation• Notes do not reveal any technical issues or intra-
operative bleeding• Given heparin 5000 units S/C at conclusion of
procedure
![Page 48: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/48.jpg)
Case 5
Recovery• PR 90/min; BP 130/65; RR 18• Minimal drainage • Obs stable over 2 hours• PCA morphine 1mg/1ml• RTW awake and stable after 2 hours in
recovery
![Page 49: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/49.jpg)
Case 5
Ward• RTW at 1500 hours• Obs done at 1530 wnl• Next obs at 1730 wnl• Next obs at 2000 – BP 86/60• No further obs documented• Nursing note entered at 2030 stated “drowsy but
rousable during shift, hypotensive at times..”
![Page 50: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/50.jpg)
Case 5
Ward• At 0030 hours found to be in cardiac arrest• Asystole –CPR, adrenaline, ROSC but
unconscious with fixed dilated pupils• Surgeon at 0100 noted no abdo distension
and minimal drainage - initially considered PE, CVA
![Page 51: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/51.jpg)
Case 5
ICU• At 0130 Hb 68 (from 120) Plts 125 (from 386)• Now 500 ml blood from drain• Considered to have suffered blood loss and
coagulopathy• By 0600 had been given 8 units blood, 4 units
FFP, platelets• By 0800 a further 2500 ml blood had drained• GCS 3 without sedation – considered likely she
had suffered hypoxic brain injury
![Page 52: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/52.jpg)
Case 5
ICU• Coagulopathy considered to be DIC from
shock secondary to cardiac arrest• Queried whether intra-abdominal
haemorrhage was due to CPR given (overt) bleeding occurred after CPR
• Surgeon sought second opinion during course of morning re laparotomy – in view of likely brain injury considered futile
![Page 53: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/53.jpg)
Case 5
ICU• Continued to bleed throughout day – further 4
units PRBC, 4 units FFP, 20 units cryoprecipitate, 4 units platelets
• Neurologist examination at 1300 noted no neuro improvement over 12 hours, GCS 3 without sedation, no focal defects suggestive of intra cranial haemorrhage – likely hypoxic brain injury with poor prognosis
• Treatment withdrawn 1730
![Page 54: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/54.jpg)
Case 5
Post mortem• 3000 ml unclotted blood in abdomen• Anastomosis intact; no injury to organs or
blood vessels found• Fat emboli found in lungs• Cause of death considered to be intra-
abdominal haemorrhage due to surgical complications.
![Page 55: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/55.jpg)
Case 5
When did the bleeding occur?• Cause of death diagnosis indicates it occurred
before cardiac arrest• Unrecognised by deficient monitoring and a lack
of blood in the drain• Blood loss caused cardiac arrest, which caused
coagulopathy and the hypoxic brain injury • No CPR injuries found hence considered due to
surgery
![Page 56: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/56.jpg)
Case 5
When did bleeding occur?• But no cause of bleeding from surgery found
either• CPR may hence have caused the bleeding • What then caused the cardiac arrest?
![Page 57: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/57.jpg)
Case 5
What about fat embolus?• Fat embolus syndrome includes hypoxia,
consumption of platelets and DIC• Mostly found after long bone fractures but
seen in cancer• Fact is that fat emboli seen at autopsy• Pathologist stated this can be a non-specific
finding hence considered unlikely
![Page 58: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/58.jpg)
Case 5
Recommendations• Decision not to operate reasonable in the
circumstances• Hospital urgently review its policies and
procedures re post-operative monitoring• Hospital conduct remedial training specifically
and on-going training generally• Staffing levels be assessed
![Page 59: CORONIAL HEALTH CARE RELATED DEATHS Dr Don Buchanan Forensic Medical Officer Queensland](https://reader035.vdocument.in/reader035/viewer/2022062408/56649e2f5503460f94b1f1fe/html5/thumbnails/59.jpg)
THE END