Inquest into the death of C Guyula
Deceased
C. Guyula
Demographics
49y, female
Date of death
2022-03-17
Finding date
2026-01-09
Cause of death
Hypoxia due to complications following incision and drainage of a right buttock abscess and inadequate reversal of anaesthetic
AI-generated summary
A 48-year-old woman with multiple comorbidities (diabetes, COPD, chronic kidney disease, ischaemic heart disease) died following complications of anaesthesia during incision and drainage of a buttock abscess. Critical failures included: inadequate reversal of neuromuscular blockade (Train of Four monitor not calibrated pre-operatively); oesophageal intubation not recognised due to misidentification of an impedance monitor as capnography; delayed detection allowing hypoxia; medication errors (Metaraminol infusion continued, Propofol not commenced); and subsequent tracheostomy dislodgement causing further hypoxic events. The chain of preventable errors resulted in permanent brain damage and death. Key lessons: mandatory Train of Four calibration before blockade administration, capnography in all post-operative areas, C-MAC video laryngoscope availability, improved staff training and communication, and documentation standards.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- Failure to calibrate Train of Four monitor prior to neuromuscular blockade administration
- Likely incomplete reversal of neuromuscular blockade (Atracurium) at extubation
- Oesophageal intubation not recognised due to misidentification of impedance monitor as capnography
- Absence of capnography monitoring in Post Anaesthetic Care Unit
- Delayed detection and correction of oesophageal intubation (5 minutes duration)
- Prolonged hypoxia resulting in hypotension and bradycardia
- Medication errors: Metaraminol infusion continued when blood pressure elevated; Propofol infusion not commenced
- Metaraminol syringe driver placed on bed rather than pole, making it difficult to visualise and stop
- Tracheostomy tube dislodgement on 13 March during pressure care
- Possible suboptimal sizing of tracheostomy tube (size 8 selected; longer tube may have been more appropriate)
- Tracheal tear discovered post-operatively (cause unclear but possibly related to intubation trauma)
Coroner's recommendations
- Mandate compliance with current ANZCA PG18 Guideline on monitoring during anaesthesia 2025
- Mandate Train of Four calibration and continuous monitoring when neuromuscular blockades are used
- Develop and institute a schedule of anaesthesia auditing to ensure compliance with mandated and recommended patient monitoring
- Improve the adequacy and accuracy of anaesthesia record keeping
- Have a dedicated C-MAC video laryngoscope available in the Post Anaesthetic Care Unit (PACU) at all times
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