Coroner's Finding: GORDON Sally Anne
Deceased
Sally Anne Gordon
Demographics
20y, female
Date of death
2000-11-30
Finding date
2006-10-30
Cause of death
Cerebral anoxia consequent upon a severe acute asthmatic event
AI-generated summary
Sally Anne Gordon, a 20-year-old with a 14-year history of severe brittle asthma, presented to Mount Gambier Hospital on 26 November 2000 with acute severe asthma unresponsive to initial treatment. After appropriate emergency management including oxygen, adrenaline and hydrocortisone, she was transferred to the High Dependency Unit where intubation became necessary. Dr N., a medical officer with 10-11 years post-graduate experience, chose pancuronium 4mg as a paralysing agent rather than suxamethonium. Expert analysis found this choice suboptimal but not causative of death. During two intubation attempts, vomiting/regurgitation occurred obscuring the vocal cords. The anaesthetist Dr G. successfully intubated on arrival but Ms Gordon arrested shortly after, suffering severe hypoxic brain damage from which she died at Royal Adelaide Hospital. The death reflects the inherent difficulties and poor prognosis in status asthmaticus rather than negligent care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Status asthmaticus unresponsive to initial medical therapy
- Delayed presentation to hospital (4 hours after symptom onset)
- Vomiting/regurgitation during intubation attempts obscuring vocal cords
- Severe hypoxaemia and cardiac deterioration prior to successful intubation
- Inadequate paralysis at first intubation attempt due to reduced pancuronium dose
Coroner's recommendations
- The coroner's findings do not contain specific recommendations, having found the death was not preventable and the medical care was appropriate
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