Inquest into the death of Brooke Tiddy

Contributing factors

• Failure to refer for pre-operative assessment despite rare condition and lack of surgeon familiarity
• Inadequate pre-operative investigation of Sponastrime Dysplasia
• Undiagnosed subglottic stenosis and tracheobronchomalacia
• Anaesthetist did not read admission documents identifying Sponastrime Dysplasia
• Lack of pre-operative communication between surgeon and anaesthetist
• Pre-anaesthetic assessment only on morning of surgery, not days/weeks prior
• Anaesthetist did not research unfamiliar diagnosis before anaesthesia
• Failure to retrieve prior anaesthetic records from 2003 surgery showing previous airway difficulties
• Loss of anaesthetic monitoring data due to failure to print records before intubation attempt

Coroner's recommendations

1. St George Private Hospital should review and amend its Compromised Airway and Difficult/Awake Intubation Policy, particularly the section on compromised airway procedures, concerning the need for pre-anaesthetic consultation and adherence to ANZCA guidelines
2. St George Private Hospital should review and amend its Admission Policy to clarify responsibility for determining that patients with chronic or complex medical conditions are carefully worked up prior to admission
3. St George Private Hospital should educate and inform doctors with admitting rights about hospital policies applicable to their practice at the hospital
4. St George Private Hospital should review its Anaesthetic Policy to require the anaesthetic technician to remind the anaesthetist to print data from the anaesthetic machine where it has not otherwise been printed to ensure it is included in the patient's medical record