Coronial
QLDhospital

Davidson, Yvonne Alice

Deceased

Yvonne Alice Davidson

Demographics

75y, female

Coroner

Hennessy

Date of death

2007-09-11

Finding date

2009-12-16

Cause of death

Septicaemia as a result of lobar pneumonia; congestive heart failure also present. Death hastened by complications from percutaneous tracheostomy procedure.

AI-generated summary

A 75-year-old woman died from septicaemia following a percutaneous tracheostomy procedure performed by a locum consultant on a Sunday. The procedure deviated significantly from the established ICU protocol: it was performed by one consultant and a junior doctor instead of two consultants, without bronchoscope visualization as required, with non-functional equipment, and without urgent clinical indication. The procedure was complicated by airway management difficulties and was abandoned. While the procedure did not directly cause death, autopsy findings suggest it hastened mortality by several days. Key failures included: inadequate locum orientation, poor communication and escalation by nursing staff, equipment issues, and the consultant's failure to review or follow the protocol despite it being available and discussed with nursing staff.

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

Specialties

intensive careanaesthesiarespiratory medicine

Error types

proceduralcommunicationsystem

Clinical conditions

pneumoniasepticaemiacongestive heart failurerapid atrial fibrillationrespiratory distresscritical illness

Procedures

percutaneous tracheostomyendotracheal intubationmechanical ventilationbronchoscopy

Contributing factors

  • Percutaneous tracheostomy performed on weekend without urgent clinical indication
  • Procedure performed in deviation from established ICU protocol
  • Only one consultant present instead of required two
  • Bronchoscope not used as required by protocol despite availability
  • Faulty or non-operational equipment (bronchoscope power lead, CO² monitor)
  • Inadequate locum orientation and lack of awareness of hospital protocols
  • Poor communication between consultant and nursing staff
  • Failure of nursing staff to escalate concerns effectively
  • Junior doctor (Dr Bernays) involved in procedure despite lack of prior experience
  • Complications during procedure including airway management difficulties

Coroner's recommendations

  1. Formal orientation for locum doctors prior to commencing duty, including procedures and policies, with clear expectation that these be adhered to
  2. Percutaneous Tracheostomy protocol to require fibre-optic bronchoscope with video screen as highly desirable for patient safety
  3. Ensure working End-tidal Carbon Dioxide monitor and bronchoscope are available in the Intensive Care Unit
  4. Percutaneous Tracheostomies be performed in normal working hours unless urgent, to enable sufficient skilled staff (including surgical and/or ENT expertise) to be available
  5. Develop escalation process for all ICU staff regarding treatment concerns, including graded assertiveness training
  6. Professional standards published by relevant medical colleges be adhered to in performance of Percutaneous Tracheostomies
  7. Queensland Health ensure that protocols and policies developed to ensure best practice are shared and communicated to doctors across all Queensland hospitals for consideration and adoption
Full text
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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.

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