Inquest into the Death of Helen Christine MacFARLAINE
Delivered on :12 August 2015
Delivered at : Perth
Finding of : Coroner Linton
Orders/Rules : N/A
Suppression Order : N/A
Summary : The deceased was a 52 year old Anglo-Indian woman who underwent elective surgery at Sir Charles Gairdner Hospital on her right-sided carotid artery. The surgery was uncomplicated and technically successful. She remained at the hospital for post-operative care for a number of days and was discharged home on 8 April 2012. The following morning the deceased suffered a catastrophic stroke and returned by ambulance to Sir Charles Gairdner Hospital. She was diagnosed with a devastating and non-survivable intracerebral haemorrhage and was admitted to the Intensive Care Unit, where she was treated palliatively until she died on 12 April 2012.
The issues which were explored at the inquest hearing were the deceased’s post-operative management at Sir Charles Gairdner Hospital, particularly in relation to the monitoring of the deceased’s blood pressure, and the decision to discharge the deceased on the morning of 8 April 2012.
The Coroner heard evidence that there had been several missed opportunities for nursing staff to raise the alert in relation to the deceased’s fluctuating blood pressure increases prior to the deceased’s discharge. The summation of the deceased’s clinical state over the preceding 24 hours given to her reviewing doctor, which was relied upon, did not properly reflect what had actually occurred. In this context the Coroner found that it was not unreasonable for the doctor to have discharged the deceased on 8 April 2012. However, the Coroner did find that the evidence disclosed that there were omissions and a lack of documentation by nursing staff that should not have occurred and if more information had been provided it might have prompted the doctor to make a different decision.
The Coroner did not find that the deceased’s death could definitely have been prevented. The Coroner found the evidence did not point conclusively to the deceased having developed a hyperperfusion state at the time she was discharged from hospital, or even that this was the definite cause of her haemorrhage, although the Coroner did accept the expert witness opinion that it was the likely cause of the haemorrhage. However the Coroner concluded that even if the deceased had developed a hyperperfusion state and it had been properly diagnosed and her blood pressure managed closely, there was no guarantee the outcome would have been any different.
The Coroner heard evidence that since the deceased’s death both individually and organisationally, changes have been made that will hopefully ensure that in a similar situation the warning signs will be heeded.
The Coroner found that the deceased died as a result of intracerebral haemorrhage in a lady with underlying cerebrovascular disease and hypertension following a recent right carotid artery endarterectomy and death arose by way of natural of causes
Catch Words : Post operative care : Adequacy of Inpatient Notes : Natural Causes.
Last updated: 21-Aug-2015
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