Coronial
VICICU

Finding into death of Hugh Peter Bourke

Deceased

Hugh Peter Bourke

Demographics

68y, male

Coroner

Coroner Dr Jane Hendtlass

Date of death

2011-01-06

Finding date

2011-09-07

Cause of death

Hypoxic brain injury and ischaemic heart disease

AI-generated summary

Hugh Peter Bourke, a 68-year-old man with a history of myocardial infarction, atrial fibrillation, and recent abdominal surgery, suffered a cardiac arrest at home on 6 January 2011. He had undergone cholecystectomy in December 2010, complicated by cholecystoduodenal fistula, followed by endoscopic retrograde cholangiopancreatography and stent placement on 31 December 2010. He was discharged on antibiotics four days before his arrest. The coroner found no evidence of preventable error. The clinical lesson emphasises appropriate post-operative follow-up and medication management in elderly patients with cardiac risk factors, particularly those undergoing complex biliary interventions. Documentation of clinical decision-making regarding continued antibiotic therapy and cardiac monitoring post-discharge would have been relevant.

AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.

Specialties

cardiologygeneral surgerygastroenterologyintensive care

Drugs involved

antibiotics

Contributing factors

  • Underlying ischaemic heart disease
  • History of myocardial infarction
  • Atrial fibrillation
  • Recent abdominal surgery and cholecystoduodenal fistula
  • Recent endoscopic retrograde cholangiopancreatography and stent placement
Full text

FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 78/11

Inquest into the Death of HUGH PETER BOURKE

Delivered On: 7 September 2011 Delivered At: Melbourne

Hearing Dates: 7 September 2011 Findings of: Coroner Dr Jane Hendtlass Representation: L/S/C Amanda Maybury Place of death/

Suspected death: Northern Hospital, 185 Cooper Street, Epping, Victoria 3076

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FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008

Court reference: 78/11 In the Coroners Court of Victoria at Melbourne I, JANE HENDTLASS, Coroner having investigated the death of: Details of deceased:

Surname: BOURKE

First name: HUGH

Address: 30 Bicknell Court, Jacana, Victoria 3047

AND having held an inquest in relation to this death on 7 September 2011 at Melbourne

Ez

find that the identity of the deceased was HUGH PETER BOURKE and death occurred on 6th January, 2011

at Northern Hospital, 185 Cooper Street, Epping, Victoria 3076 from

la. HYPOXIC BRAIN INJURY 1b. ISCHAEMIC HEART DISEASE

In the following circumstances:

  1. Hugh Peter Bourke was 68 years old when he died. He lived in community residential

accommodation at 30 Bicknell Court in Jacana. Mr Bourke’s medical history imcluded

myocardial infarction, intellectual impairment, atrial fibrillation, supraventricular tachycardia,

anxiety and cholangitis associated with a chronic cough. His general practitioner was Dr Bao

Nguyen.

  1. On 1 December 2010, Mr Bourke underwent an open cholecystectomy at Northern

Hospital and was diagnosed with a cholecysto-duodenal fistula, His medication was adjusted and

his cough continued.

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3, On 20 December 2010, Dr Nguyen noted continuing cough and prescribed antibiotics but, on 22 December, he referred Mr Bourke for further investigation, On 31 December, Mr Bourke underwent endoscopic retrograde cholangiopancreatography and stent placement, On 4 January 2011, he was discharged home on antibiotics.

  1. At 8.40am on 6 January 2011, Mr Bourke suffered a cardiac arrest at home while he was sitting at the breakfast table after taking his morning medication. He was resuscitated and transferred to the Intensive Care Unit at Northern Hospital in Epping. However, his prognosis was poor and active treatment was withdrawn.

  2. At 2.55pm on 6 January 2011, Hugh Bourke died.

  3. The forensic pathologist who inspected the body and CT scans, formed the opinion that a reasonable cause of death in the circumstances would be hypoxic brain injury and ischaemic

heart disease.

  1. Accordingly, I find that Hugh Bourke died from hypoxic brain injury and ischaemic heart

ae Dr Jane H¢ndtlass Coroner

7 September 2011

WA

disease.

Signature:

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