Coroner's Court of Western Australia

Inquest into the Death of Edith Catherine Bee

Delivered on 3 May 2017 at Perth.

Finding of Deputy State Coroner Vicker.


The deceased was 80 years of age at the time of her death and who had undergone an endoluminal graft repair of an atherosclerotic aortic aneurysm.

On 4 September 2013 the deceased underwent a procedure which was carried out at Hollywood Private Hospital by a vascular and general surgeon, under anaesthetic which required the use of carbon dioxide and a contrast to assist with visualising of the blood vessels during repair of the aneurysm.

During the procedure the deceased suffered a cardiac arrest and required resuscitation. While the anaesthetist was aspirating the central vein catheter, gas was found in the tubing and a cardiologist was called to assist. Gas was found in the femoral vein following access to the groan. The deceased could not be revived.

An expert endovascular and specialist vascular surgeon reviewed the medical management of the deceased for the endoluminal aneurysm repair which necessitated a custom made, fenestrated two piece graft which involved the coeliac, superior mesenteric and two renal arteries.

The expert witness at the inquest hearing was critical of the methodology used for delivery of the carbon dioxide needed for the imaging due to the deceased’s renal disease. The critical issue was the ability for carbon dioxide to be delivered directly to the deceased’s vascular system, under pressure from the carbon dioxide cylinder, and by-pass the syringe regulating the amounts.

The vascular and general surgeon accepted the three-way tap had allowed for the potential of a direct injection of carbon dioxide under pressure, to the deceased’s vascular system.

This could not occur with a two-way tap with a proper locking mechanism between the carbon dioxide cylinder, syringe and patient and believed this must have occurred accidentally during the procedure when the delivery system was placed alongside the deceased while not in use.

The vascular and general surgeon was certain the taps were turned off at the appropriate times when the carbon dioxide for imaging was used and was aware of the dangers of the direct injection of carbon dioxide into a patient, under pressure and in unsupervised amounts.

It was because of these concerns the vascular and general surgeon had customised a delivery system utilising a two-way tap which had not been used on this occasion.

The Deputy State Coroner found the use of the three-way tap for delivery of carbon dioxide during angioplasty had allowed carbon dioxide to accidentally enter the deceased’s vascular system in an unsupervised and pressurised manner, causing a fatal gas embolism and resulting in the deceased’s death.

The Deputy State Coroner was satisfied the deceased died as a result of gas embolism complicating surgical repair of an atherosclerotic aortic aneurysm, and that the deceased’s age and multiple comorbidities necessitated the use of carbon dioxide in conjunction with standard contrast to visualise the vascular system appropriately during the deceased’s procedure.

The Deputy State Coroner found death occurred by way of Misadventure.

Catch Words

Endoluminal graft repair : Gas embolism : Use of carbon dioxide delivery system : Misadventure.

Last updated: 25 August 2022

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