Findings Into The Death Of Sukanya Thurairajah
Deceased
Sukanya Thurairajah
Demographics
56y, female
Date of death
2011-08-08
Finding date
2014-03-03
Cause of death
hypoxic ischaemic encephalopathy due to inadvertent oesophageal intubation and failure to provide oxygen in a timely manner
AI-generated summary
Sukanya Thurairajah, 55-year-old with multiple comorbidities including obesity, diabetes, coronary disease, and metastatic breast cancer, underwent haemodialysis at Canberra Hospital on 29 July 2011. She had an adverse reaction characterised by vomiting, breathlessness and hypertension. MET team intubation was performed by first-year anaesthetic registrar Dr T., who had never previously performed emergency intubation. The tube was inadvertently placed in the oesophagus rather than trachea, resulting in approximately 18 minutes of hypoxia until recognised and corrected by Dr D. Multiple contributing factors included: difficult airway anatomy, chaotic MET environment, inadequate team leadership and communication, failure to promptly utilise capnography monitoring (gold standard), and false reassurance from tube fogging and breath sounds. The patient suffered severe hypoxic-ischaemic encephalopathy with no meaningful neurological recovery, leading to withdrawal of treatment and death on 8 August 2011. Key lessons: junior trainees performing emergency intubation for first time require closer supervision; capnography must be applied immediately and interpreted; team communication and role clarity are essential in chaotic emergencies.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- inadvertent oesophageal intubation by first-year anaesthetic registrar
- failure to recognise misplaced endotracheal tube
- delay in activating or recognising end-tidal carbon dioxide monitor
- false reassurance from tube fogging and bilateral air entry on auscultation
- chaotic MET environment with poor team leadership
- poor communication between MET team members
- lack of assertiveness by nursing staff in voicing concerns
- difficult airway anatomy due to large jaw and neck
- vomiting and reduced consciousness
- lack of familiarity with equipment on MET trolley
- lack of supervision of junior anaesthetic registrar with no prior emergency intubation experience
- absence of clear role assignment and delineation of responsibilities
Coroner's recommendations
- Require all MET-pager-carrying or MET-attending staff to complete annual documentation confirming familiarity with MET policies, procedures, and equipment on the MET trolley
- Amend the 'Responders roles and responsibilities' document to include a recommended introduction format on arrival at medical emergencies, specifying: name, role, years/months of experience in that role, and clarification of who is in charge of the response
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