Coronial
NThospital

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. Report an inaccuracy.

Specialties

anaesthesiasurgeryintensive careemergency medicineENT surgery

Error types

proceduralmedicationcommunicationdiagnosticdelay

Drugs involved

fentanylpropofolatracuriumnaloxoneatropineadrenalinemetaraminol

Clinical conditions

hypoxiaoesophageal intubationincomplete neuromuscular reversalcurarisationbradycardiahypotensionhypertensioncardiac arrestcomaanoxic brain injurytype 2 diabetes mellituschronic kidney diseasechronic obstructive pulmonary diseaseischaemic heart diseasecerebrovascular diseaserheumatic heart diseasetracheal teartracheostomy dislodgement

Procedures

incision and drainage of abscessendotracheal intubationreintubationtracheostomybronchoscopyfemoral arterial line insertion

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

  1. Mandate compliance with current ANZCA PG18 Guideline on monitoring during anaesthesia 2025
  2. Mandate Train of Four calibration and continuous monitoring when neuromuscular blockades are used
  3. Develop and institute a schedule of anaesthesia auditing to ensure compliance with mandated and recommended patient monitoring
  4. Improve the adequacy and accuracy of anaesthesia record keeping
  5. Have a dedicated C-MAC video laryngoscope available in the Post Anaesthetic Care Unit (PACU) at all times
Full text
Official source Archived copy

Related cases from NT

NThospital2025-03-25

Inquest into the death of Judith Smart

66y · Female·Hypoxic-ischaemic encephalopathy

A 66-year-old woman with COPD, obstructive sleep apnoea, and obesity underwent routine knee surgery at Royal Darwin Hospital. Post-operative care was inadequate. Despite dropping oxygen saturations to 88% when sedated an…

anaesthesiaorthopaedic surgerydiagnosticsystemmorphine
NThospital2019-04-16

Inquest into the death of Ali Achmadun Djawas

70y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …

Ali Djawas, a 70-year-old Indonesian-born man with comorbidities (hypertension, diabetes, COPD), underwent elective right hemicolectomy on 13 March 2017 for a suspicious ileo-caecal lesion. Biopsies were benign, CT imagi…

colorectal surgerygeneral surgerydiagnosticcommunicationmethylnatrexone
NThospital2018-09-21

Inquest into the death of David Fensom

67y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …

David Fensom, 67, underwent elective fundoplication for hiatus hernia and reflux on 21 September 2010. He developed severe right-sided abdominal pain post-operatively. A laparoscopy on 8 October misinterpreted findings a…

general surgeryemergency medicinediagnosticcommunicationfentanyl

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.