Inquest into the death of Shirley Elizabeth Haggett

Contributing factors

• ASA 4 patient admitted to day surgery facility licensed only for ASA 1-3
• Inadequate pre-operative assessment of respiratory function
• High-flow, high-concentration oxygen administration in CO2 retainer for >2 hours causing hypercarbia and hypercarbic narcosis
• Failure to recognise post-operative deterioration despite concerning vital signs
• Delay in transfer to ICU
• Aspiration event
• Anaesthetist fixation error and inappropriate post-operative plan
• Systemic failures in escalation and communication at day hospital
• Inadequate monitoring capabilities in recovery unit for complex patient

Coroner's recommendations

1. Systems improvements at day hospitals to prevent admission of patients beyond licensing scope, including automated checks and clear communication of licence limitations to all visiting medical officers
2. Pre-operative anaesthetic assessment should occur prior to day of surgery for complex/high-risk patients
3. Anaesthetists should conduct thorough pre-operative history including specific inquiry about home oxygen use and CO2 retention status
4. Protocols for early escalation and MET call criteria should be clear and readily accessible
5. Equipment suitable for managing complex patients should be available at day surgery facilities admitting such patients
6. Post-operative observation periods should be adequate with clear management plans documented
7. Nursing staff should be empowered to escalate concerns and arrange transfer without undue administrative barriers
8. Training should address recognition of CO2 retention risk and appropriate oxygen delivery methods
9. Day surgery facilities should have clear pathways for arranging ICU transfers
10. Clinical leadership should be actively involved in oversight of patient care and escalation decisions