Inquest into the death of Francis Kamaranga
Deceased
Francis Kamaranga
Demographics
28y, male
Date of death
1999-02-18
Finding date
2000-09-06
Cause of death
asphyxiation following severe swelling to the larynx due to anaphylactoid reaction to Haemaccel
AI-generated summary
A 28-year-old Aboriginal male died from anaphylactoid reaction to Haemaccel, a plasma volume expander administered pre-hospital following a severe laceration to the radial artery. Initial management was appropriate, but anaphylaxis was not recognized until 2:05am despite clear symptoms from 1:47am (swollen tongue, facial swelling, gurgling breathing). Adrenaline, the standard emergency treatment for anaphylaxis, was delayed until recognition of the condition. Clinical lessons: maintain high suspicion for anaphylaxis even when alternative diagnoses seem plausible; early recognition allows prompt adrenaline administration which may alter outcomes. The surgical airway was difficult given massive swelling but appropriately performed. Broader learning: anaphylaxis can be triggered by blood products and Haemaccel; reactions may be delayed up to 60 minutes and triggered by dose volume/rate rather than initial administration; alcohol may potentiate histamine release.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- delayed recognition of anaphylaxis
- delayed administration of adrenaline
- severe angioedema rendering intubation impossible
- Haemaccel anaphylactoid reaction due to manufacturing process change
- high blood alcohol content potentially potentiating histamine release
Coroner's recommendations
- Early recognition and treatment of anaphylaxis should be emphasized in training; this case should form part of training regime for accident and emergency staff
- Preparation of emergency packs containing intubation tube and jointing equipment to support cricothyroidotomy management
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