A sudden patient death – Under the inquest microscope

A sudden patient death raises many questions with the purpose of a coronial investigation being to find the answers. This can be a lengthy and stressful process for the doctors called before the court.

In this four-year investigation, several doctors were required to report on a surprising turn of events where a patient who appeared to be in relatively good health, suddenly passed away.

The case* demonstrates the importance of being rigorous about your clinical decision-making and documenting this process, so there is no doubt in the coroner’s mind as to what occurred.

Surgical option pursued

The patient was referred to a specialist upper gastrointestinal and bariatric surgeon, due to health issues as a result of her weight. She had a history of gastro-oesophageal reflux disease, increased body mass index, ischaemic heart disease, hypertension, high cholesterol and kidney cancer. The patient had a gastric band in situ with a pouch and oesophageal dilation.

Over the past few years she had tried multiple treatments to control her weight, however, none were successful. Despite maximal medical therapy and the previous surgery, she found only minor improvement in her symptoms and further surgical options were explored. The patient decided to undergo revisional gastric bypass surgery, which was performed by the surgeon at a private hospital. The surgery was successfully completed.

Post-surgery, the patient received routine antibiotics and deep vein thrombosis (DVT) prophylaxis. She wore compression stockings, pneumatic calf compressors and was provided with patient-controlled analgesia.

Slow recovery perplexing

The patient developed a low grade fever two days after the procedure and a C-reactive protein (CRP) blood test showed elevated levels. She began to complain of increased abdominal pain in the epigastric region, although her vitals were normal.

An abdominal computed tomography scan identified a mild collapse of the lung bases with small pleural effusions, an epigastric hernia and a possible small bowel perforation.

A laparoscopy was undertaken by the surgeon, who found all components of the bypass surgery intact. There was no bowel perforation, the hernia was repaired and the patient was put onto intravenous antibiotics.

While initially seeming to make a recovery, two days after the laparoscopy the patient said she was feeling nauseous, and was sweating and pale. It was noted one of the antibiotics might have been contributing to her nausea, which dissipated later in the day.

In the early hours of the morning, the medical emergency team (MET) was called as she was feeling unwell again and perspiring. A night intensive care unit (ICU) registrar attended.

Upon examination, she noted that the patient had mild tachypnoea but otherwise was looking well. The patient had a supplemental oxygen requirement that was unchanged for days and, when asked, said she didn't have any chest pains or shortness of breath.

Blood tests, an electrocardiogram, blood cultures, venous blood gases, lactate and a full blood count were requested, and a review was scheduled for later that morning. The registrar completed a handover to the day ICU registrar at 8am, flagging that the patient would need a follow up.

She again seemed well during the follow up and had stable vital signs. Her haemoglobin levels were lower than the previous morning but still within normal range. She was monitored for possible bleeding.

She again expressed she was feeling poorly later in the day and was dizzy following her shower. CRP had reduced and her haemoglobin was starting to stabilise.

A rapid decline

Just after midday the patient suffered a cardiac arrest. She was revived after a brief period of cardio pulmonary resuscitation and multiple doses of adrenaline. She was intubated and transferred to the ICU.

She suffered another cardiac arrest within a half hour and was given further doses of adrenaline as well as alteplase, as pulmonary embolism was suspected as the cause of her haemodynamic instability.

The patient was stable for a further two hours although she had developed impaired liver and kidney function as well as severe acidosis. That afternoon she died after another cardiac arrest.

An autopsy identified pulmonary thromboemboli in the left pulmonary artery and middle lobe of the right lung as well as DVT in the left lower leg. The anastomosis from the gastric bypass surgery was intact.

The patient's case was brought to the attention of the coroner as a reportable death.

An unavoidable outcome

All the doctors involved in the patient's care were required to provide a statement to the coroner.

We assisted them in preparing the reports, explaining the basis for their management of the patient and the reasoning behind their decision-making.

After reviewing all the investigative material, the coroner decided to hold an inquest to clarify the cause of the death and the circumstances in which it occurred.

Avant Law coordinated the preparation for the inquest and supported the members in telling their side of the story at court.

There were a number of areas the coroner focused on during the inquest; whether the surgical risks were appropriately addressed and whether the patient's condition could have been diagnosed at the MET call, the review or at a later stage on the day she died.

The coroner was particularly interested to understand from the surgeon whether the patient was provided with sufficient anti-coagulation before, during and after surgery and whether there were any “missed opportunities” to diagnose a pulmonary embolus (PE) in this case.

Coroner declares care was appropriate

Ultimately, the coroner found that the patient’s care was appropriate and reasonable based on the information available to the respective members.

It was highlighted there was less than 1% chance of PE in the patient’s case and that the surgeon took precautions in line with common practice to address the risk.

The coroner was complimentary of the night ICU registrar's response to the MET call, noting the examination was thorough and appropriate. She explored three differential diagnoses including PE and documented this along with a management plan. Similarly, the follow up was properly undertaken.

The coroner reinforced the importance of a multidisciplinary team approach to patient care. Ensuring clinical entries into hospital records reflect the doctor’s thinking and treatment plan – as was in this case – was also highlighted.

Whilst it was most surprising this case could reach the level of an inquest, it was pleasing the process resulted in sensible conclusions, affirming the clinical management of the patient.

Whilst it was most surprising this case could reach the level of an inquest, it was pleasing the process resulted in sensible conclusions, affirming the clinical management of the patient.

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Avant member involved in the case

Useful resources

Read our factsheet The coroner and you, and articles Are we all clear? Multidisciplinary careand On the record: the importance of keeping good medical notes.

This article was originally published in Connect Issue 12.

*Some details in this case study have been changed.