Non-inquest findings into the death of Mrs NSM

4 mins  23.08.2017

Unexpected death of an 81 year old woman following the insertion of a permanent pacemaker

Mrs NSM was 81 years old with a history of high blood pressure and high cholesterol, for which she was medicated. She also suffered from severe curvature of the spine and osteoporosis. Three months prior to her death, Mrs NSM was referred to a Cardiologist at a private hospital to investigate suspected cardiac issues. A 24 hour heart monitor was used to diagnose sick sinus syndrome. Mrs NSM was referred to a tertiary public hospital for the purpose of having a pacemaker insertion.

On 10 April 2014, Mrs NSM was transferred to the Coronary Care Unit (CCU) of the public hospital for an elective pacemaker insertion. The procedure was described as routine with no complications noted. Difficulty did arise with the initial puncture and a second puncture was required in order to pass the wire through successfully. Following the procedure, ooze was noted from the insertion site, which was treated with digital pressure. No external active bleeding was visible, although swelling was noted around Mrs NSM's neck.

Upon return to the CCU Mrs NSM complained of ongoing chest pain and appeared pale. An echocardiogram was performed and intravenous morphine and Ondansetron for pain and nausea were administered. Mrs NSM continued to complain of chest pain and was reviewed by the supervising Clinical Nurse, the attending medical officer and a Consultant. At approximately midnight on 11 April 2014, Mrs NSM was woken so observations could be performed and immediately complained of strong central chest pain. Mrs NSM's blood pressure had dropped to 80/50 by this time and a senior night medical officer was called to conduct a review as her condition was deteriorating.

At 1.00am on 11 April 2013 a chest x-ray was performed due to Mrs NSM's ongoing chest pain and shortness of breath. The senior medical officer requested assistance from the Intensive Care Unit (ICU) medical officer to insert a chest drain for suspected pneumothorax. At this time Mrs NSM's systolic blood pressure was 60. At 1.38am a MET call was initiated and the ICU medical officer preformed a needle decompression of a suspected tension pneumothorax followed by the insertion of an intercostal chest drain. Blood exuded from the drain. Mrs NSM was given 0.5mg of metaraminol in an attempt to raise her blood pressure. A bedside ultrasound showed a small pericardial effusion with global hypo contractility.

Mrs NSM continued to deteriorate, she had to be intubated and at around 4.00am was taken into the operating theatre for an emergency thoracotomy, where a large amount of blood was found in her chest cavity. Further life saving measures proved futile and Mrs NSM was declared deceased at 6.50am on 11 April 2014.

Findings

Following Mrs NSM's death, the public hospital carried out a Root Cause Analysis (RCA). The RCA review team noted that Mrs NSM's death was reasonably unexpected, and was contributed to by systemic factors identified by the review process. These factors included the delay to recognise and manage a deteriorating patient due to utilisation of a standard single response system observation chart, and differing practices in relation to risk management between clinicians as demonstrated by pre-procedure venograms and post-procedure chest x-rays.

Recommendations were made following the RCA including the implementation of a cardiac specific Q-ADDs chart, amendments being made to the pacemaker clinical pathway to include indications of arterial injury and steps be taken to implement a best practice workplace protocol for ultra-sound guided cannulation instead of the landmark method, which was utilised in Mrs NSM's treatment. At the time of findings being made, the hospital had taken steps to implement the recommendations of the RCA report.

The Coroner had regard to the report provided by Dr Kenneth Hossack which detailed his views as to the sufficiency of care and treatment provided to Mrs NSM. Dr Hossack noted that the complications experienced by Mrs NSM were recognised complications, although the risk of these complications eventuating was less than 1%. Further, Dr Hossack noted that there were a number of factors in her clinical presentation which were misinterpreted or ignored during Mrs NSM's post-operative care. The Heath Service made a number of submissions in response to Dr Hossack's report, noting that many of the shortcomings he identified had been addressed through the RCA process.

The Coroner was satisfied that the concerns raised by Dr Hossack had been carefully and extensively considered by the Hospital and those involved in Mrs NSM's management and post-operative care. Additionally the Coroner noted that the Hospital had carried out an extensive investigation and had implemented the widespread recommendations made. The Coroner was accordingly satisfied that the clinical treatment and care concerns arising from this matter had been satisfactorily addressed. As such, an inquest into Mrs NSM's death would not be in the public interest and it was appropriate for the matter to be closed by way of written findings.

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