Coronial
NSWhospital

Inquest into death of Andrea LESTER

Deceased

Andrea Lester

Demographics

49y, female

Coroner

Decision ofDeputy State Coroner Kennedy

Date of death

2018-06-19

Finding date

2022-12-21

Cause of death

Hypoxic brain injury related to tracheostomy complications in form of airway occlusion from sputum plugging and/or tube dislodgment

AI-generated summary

Andrea Lester, age 49, suffered a subarachnoid haemorrhage from a PICA aneurysm in March 2018 with delayed diagnosis. Following complex neurosurgery causing Wallenberg syndrome, she required tracheostomy for bulbar dysfunction. On 13 June 2018, she suffered cardiorespiratory arrest due to airway occlusion from sputum plugging and/or tube dislodgment while a tracheostomy cap (not the planned speaking valve) was in place. The cap was applied without team authorization by nursing staff who were not adequately trained to distinguish between equipment types. Critical systemic failures included: uncoordinated multidisciplinary management without senior medical bedside involvement; failure to recognize Ms Lester had not met safe decannulation criteria despite ongoing heavy secretions and recent chest infection; poor documentation and handover; inadequate staff education on tracheostomy management due to infrequency of such patients on the ward; and failure to escalate after a near-fatal incident on 6 June involving the same equipment confusion. The coroner found this death potentially preventable through proper team coordination, staff training, senior medical oversight, and adherence to existing clinical policies.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

neurosurgeryintensive careENT surgeryspeech pathologyphysiotherapyemergency medicine

Error types

diagnosticcommunicationsystemdelayprocedural

Drugs involved

tramadolglycopyrroniumnimodipinecefalexinenoxaparinamphotericinflucytosinefluconazolemidazolamfentanylpropofol

Clinical conditions

subarachnoid haemorrhagePICA aneurysmwallenberg syndromebulbar dysfunctionhydrocephalusvasospasmischaemic strokeaspiration riskpneumoniaventilator-associated pneumoniafungal ventriculitiscandida parapsilosisdeep vein thrombosisbrain injuryseizure

Procedures

tracheostomy insertiontracheostomy downsizingendovascular repairexternal ventricular drain insertionintubationcuff deflation trialspeaking valve applicationtracheostomy cap trialneurosurgery for EVD insertion

Contributing factors

  • Tracheostomy cap placed instead of speaking valve
  • Cap applied without team authorization
  • Nursing staff confused between tracheostomy cap and speaking valve
  • Patient did not meet safe decannulation criteria
  • Ongoing heavy secretion load not well controlled
  • Recent chest infection with antibiotics only ceased day before death
  • Inadequate staff training and competency in tracheostomy management
  • Lack of formal coordinated multidisciplinary team approach
  • Insufficient senior medical bedside involvement in care planning
  • Poor documentation of secretion frequency and suctioning requirements
  • Failure to escalate after near-fatal incident on 6 June 2018
  • Unclear and inconsistent handover of treatment plan during long weekend
  • Inadequate supervision and one-on-one nursing despite cognitive impairment
  • Patient unable to use call bell due to position of bed
  • Infrequency of tracheostomy patients on ward leading to poor skill maintenance
  • Limited ENT specialist review prior to decannulation attempt

Coroner's recommendations

  1. The role of ICU Consultants (or ICU representatives on the Tracheostomy Review Team) must include a requirement to attend bedside MDT reviews for patients with tracheostomies on outlying wards such as Ward C4 West
  2. The ENT/Head & Neck Clinical Nurse Specialist 2 role be increased from part-time to full-time position
  3. The Executive Director of Nursing and Midwifery Services ensure nursing staff available to provide care for tracheostomy patients in Ward A5, Ward C4 West, and any other wards within Wollongong Hospital (other than ICU) are competent in tracheostomy management, with regard to competency assessments by the ENT/H&N CNS 2
  4. The Executive Director of Nursing and Midwifery Services ensure Nurse Unit Managers are aware of the obligation to ensure nursing staff rostered for tracheostomy patients in Ward A5, Ward C4 West, and other wards are competent in tracheostomy management
  5. Recommendations 1-4 be actioned as a matter of urgency given the significant clinical risk associated with tracheostomy management on outlying wards that do not frequently have such patients
  6. The Chief Executive of ISLHD give consideration to the use of appropriate equipment for constant monitoring of oxygen levels with alarm systems when weaning tracheostomy patients who have decreased levels of consciousness or cognitive impairment
Full text
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