Record of Investigation Into Death
Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4
I, Stephen Raymond Carey, Coroner, having investigated the death of
Ann SNAPE
WITHOUT HOLDING AN INQUEST
Find :
a) The identity of the deceased is Ann Snape ("Mrs Snape") who died on 24 July 2011 at the Royal Hobart Hospital.
b) Mrs Smith was born on 13 December 1927 and was aged 83 years.
c) Mrs Snape was widowed.
d) Mrs Snape died as a result of multiple organ failure due to pneumothorax and haemothorax following the insertion of a pacemaker for cardiac arrhythmia. Contributing factors were a fracture of the right femur following an unwitnessed fall, metastatic carcinoma of the lung and renal failure.
Circumstaces Surrounding the Death :
Mrs Snape suffered a fractured right femur in an unwitnessed fall at her home on 13 July 2011 and was found by her daughter on the floor of their residence a few hours later. Mrs Snape was admitted to a ward at the Royal Hobart Hospital in the early hours of 14 July 2011 where surgery was proposed to be carried out to fix the fracture in her femur. The day following her admittance she experienced a period of unresponsiveness and was assessed by a Cardiologist as a result of which she was transferred to the Cardiology Ward for monitoring.
On 15 July 2011 Mrs Snape was assessed, as a result of her suffering intermittent periods of complete heart block, to require the urgent insertion of a cardiac pacemaker. During this procedure she had to have an intravenous catheter placed into her subclavian vein and this is noted to have been very difficult. She required multiple punctures, suffered bleeds and as a result a transfusion of red blood cells was required. Mrs Snape developed a pneumothorax related to either the insertion of the subclavian line or the pacemaker wiring. An intercostal catheter was inserted to treat the pneumothorax and Mrs Snape was admitted to the high dependency unit.
Over the next two days Mrs Snape's condition deteriorated and as a result of the risks of further general anaesthesia, discussions were held with Mrs Snape's family and it was decided to provide Mrs Snape with palliative and comfort care. She died in the early hours of 24 July 2011.
Dr Lawrence further states:
"Autopsy reveals a perforation of the posterior wall of the left subclavian vein which appears to have entered the pleural cavity. There is a mucinous adenocarcinoma of the right lung which has metastasised to the adrenal gland. There is calcification adjacent to the AV node which may have caused the cardiac arrhythmia. There is also damage to the apex of the right ventricle due to the pacing wire".
Comments and Recommendations :
I find that Mrs Snape died as a result of multiple organ failure due to pneumothorax and haemothorax following the insertion of a pacemaker for cardiac arrhythmia. Contributing factors were a fracture of the fight femur following an unwitnessed fall, metastatic carcinoma of the lung and renal failure.
Although possible complications were known prior to the surgical procedure performed on Mrs Snape and although what occurred was adverse this was not necessarily due to poor technique or other operator-related or systems issues. I also accept that Mrs Snapefs pneumothorax and blood loss were quickly detected and treated appropriately and that although the perforation of Mrs Snapefs myocardium was not detected she was asymptomatic in that regard.
Before concluding I would like to convey my sincere condolences to the family of Mrs Snape.
Dated this 12 day of January 2012