Mr DAC died on 26 June 2017 at the age of 51 years. Mr DAC's death was a result of sepsis, right lower limb necrotising fasciitis as a result of right inguinal femoral artery pseudo-aneurysm, coronary atherosclerosis and ischaemic heart disease, sarcoidosis.

Background facts

In April and May 2017, Mr DAC presented to his local hospital on a number of occasions with chest pain. He was then regularly referred on to another hospital for treatment. On 10 May 2017, an angiogram of Mr DAC revealed a stenosis of the left anterior descending coronary artery. Mr DAC had a stent inserted and was discharged. On Mr DAC's return to the hospital on 16 May 2017, he was diagnosed with pseudo-aneurysm (a false aneurysm that happens with the wall of a blood vessel is injured and leaks blood that is contained in the surrounding tissue) that arose from the distal common femoral artery. Mr DAC underwent eight surgical procedures with prolonged antibiotics as there was an absence of an identifiable infective organism. Despite aggressive treatment for infection, Mr DAC died on 26 June 2017.

Mr DAC was 51 years old and had a past medical history of obesity, advanced kidney cancer, kidney removal in 2009, spread of a tumour to the chest cavity and ribs in 2013, bleeding within the skull in 2014 which lead to a resection of brain metastases in 2015 and presumed pancreatic metastases on CT scan, a clot in a vein which dislodged and travelled to the lung in 2015, sweet's syndrome secondary to chemotherapy medication and sarcoidosis.

Autopsy report

Following his death, a partial internal and external post-mortem examination was conducted on 26 June 2017. An Associate Professor conducted an examination and noted that Mr DAC had co-morbidities including metastatic renal cell carcinoma and a right nephrectomy, giving him a prognosis for survival of one year.

The Associate Professor was of the opinion that Mr DAC was more prone to sepsis because of the therapy for renal cell carcinoma. It was also reported that Mr DAC's co-morbidities of sarcoidosis and ischaemic heart disease would have contributed to his death.

Mr DAC's cause of death was deemed to be sepsis because of or as a consequence of an infection caused by bacteria that spread into the subcutaneous tissue and fascia of his right lower limb. This occurs because of the stent insertion and ischaemic heart disease.

Human Error and Patient Safety (HEAPS) Incident Analysis Report

HEAPS reported that a pseudo-aneurysm is a common complication of angiogram, though the cardiology team should have been advised that Mr DAC required re-admission. However, the conclusion in the report was that this would not have changed the care received by Mr DAC as the vascular team was the appropriate speciality team to treat him.

It was concluded that Mr DAC's death was an unfortunate consequences of his metastatic malignant disease, drug therapy and other comorbid conditions.

Clinical Forensic Medicine Unit (CFMU) review

A Forensic Specialist provided a report in August 2018 after reviewing the medical records and autopsy report. The Forensic Specialist was not critical of the care Mr DAC received from his local hospital as he was appropriately assessed and promptly transferred to another hospital for treatment. He also noted that the infection and pseudo-aneurysm at the femoral artery access site are common complications to have occurred. The number of comorbidities contributed the Mr DAC's failure to recover from the infected pseudo-aneurysm. A long term use of steroids and anti-cancer drugs also contributed to an increased risk of infection and effected his wound healing.

Cardiologist report

A Cardiologist provided a report in May 2019, after also reviewing the medical records. The Cardiologist was critical of the treating hospital's choice to treat Mr DAC with pain medication and prescribed aspirin. He considered that Mr DAC 'unequivocally' met the criteria for ST elevation myocardial infarction and should have been treated with a beta blocker and statin drug.

The Cardiologist was also critical of the Doctor's choice to not conduct a pre-procedure evaluation which was necessary given the complexity of Mr DAC's co-morbidities. He states, 'had Dr R properly assessed Mr DAC prior to angiography he would have chosen a radial approach which allows a much greater chance of achieving haemostasis following the procedure'. He is also of the opinion that the post-operative management of Mr DAC's bleeding was 'negligent and below the standard of care'. He notes that a competent cardiologist with the knowledge of Mr DAC's dual anti-platelet therapy, Rivaroxaban and two episodes of bleeding into the groin would have then completed an ultrasound of the femoral artery to exclude the possibility of pseudo-aneurysm and confirm closure of the femoral artery. The Cardiologist stated, ' failure was the single most important factor that resulted in the death of Mr DAC' and that this was the 'major cause of the sequence of events resulting in Mr DAC's demise'.

Conclusion

The Coroner concluded that Mr DAC's cause of death was due to:

1(a). Sepsis, due to or as a consequence of

1(b). Right lower limb necrotising fasciitis, due to, or as a consequence of

1(c). Right inguinal femoral artery pseudo-aneurysm (bypass surgery), coronary atherosclerosis (angioplasty-stent insertion).

2. Ischaemic heart disease, Sarcoidosis.'

In consideration of the investigations as summarised above, the investigation did not proceed to inquest as it would not be in the public's interest.