R - Non-inquest findings

Contributing factors

• Post-extubation laryngospasm causing post-obstructive pulmonary oedema
• Acute respiratory tract infection (Rhinovirus and CMV)
• Endotracheal tube malpositioning and migration to oesophagus
• Failure to maintain continuous capnography monitoring during resuscitation
• Inadequate assessment of endotracheal tube position using single clinical parameters
• Failure to investigate persistent gastric distension as indicator of tube malpositioning
• Blood and ooze complicating tube securement
• Unclear resuscitation team roles and communication breakdown
• Position changes required for ECMO cannulation compromising airway management

Coroner's recommendations

1. Implement continuous capnography for all patients with tracheal tubes who are intubated and ventilator dependent unless clinical exception exists
2. Use end-tidal CO2 monitoring when patients require manual ventilation, disconnection from ventilator for suctioning, and during transport
3. Use colorimetric CO2 detectors if waveform capnography not immediately available
4. Maintain EtCO2 monitoring attached to bag during disconnection from ventilator, manual ventilation, and suctioning
5. Establish nationally recognised clinical recommendations for airway management in intensive care units
6. Implement single unified guideline for intubation and ventilation management by medical and nursing staff
7. Incorporate capnography interpretation into clinical guidelines, including use during CPR
8. Develop clear protocols for identifying and managing endotracheal tube obstruction and displacement
9. Investigate persistent gastric distension as potential indicator of endotracheal tube malpositioning
10. Improve handover procedures and role assignment during emergency resuscitations
11. Establish consistent identification of airway doctor and nurse roles at commencement of resuscitation
12. Provide regular airway training and practice for medical and nursing staff