Coronial
QLDhospital

R - Non-inquest findings

Demographics

<1y, male

Date of death

2020-07-31

Finding date

2022-07-08

Cause of death

Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distress requiring intubation and ventilation, complicated by cardiorespiratory arrest of unknown cause, following cleft palate repair surgery

AI-generated summary

A 10-month-old boy died following elective cleft palate repair surgery complicated by post-operative respiratory distress and subsequent cardiorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pulmonary oedema requiring intubation. During PICU management, multiple opportunities were missed to verify endotracheal tube positioning: continuous capnography was disconnected during resuscitation, abdominal distension suggesting possible oesophageal intubation was not adequately investigated, and the tube's position was never directly visualized despite clinical concerns. The tube eventually migrated to the oesophagus. Key lessons: implement continuous capnography for all intubated patients, verify tube position with multiple assessment methods (not auscultation alone), investigate gastric distension as a sign of tube malpositioning, maintain capnography during manual ventilation and CPR, and ensure clear airway role assignment during resuscitations.

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

Specialties

anaesthesiaintensive careplastic and reconstructive surgeryemergency medicinerespiratory medicinecardiothoracic surgeryoral and maxillofacial surgery

Error types

diagnosticproceduralcommunicationsystem

Drugs involved

propofolfentanylmorphinedexmedetomidinevecuroniummidazolammetaraminol

Clinical conditions

cleft palatecleft lippost-obstructive pulmonary oedemalaryngospasmrespiratory distressupper respiratory tract infectionrhinovirus infectioncytomegalovirus infectiongastric distensionhypoxic ischaemic encephalopathydiffuse alveolar damagecardiorespiratory arrest

Procedures

cleft palate repairmyringotomytympanostomy tube insertionintubationextubationendotracheal tube repositioningre-intubationECMO cannulationcardiopulmonary resuscitation

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
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