Coronial
SAhospital

Coroner's Finding: LYNN Matthew John

Deceased

Matthew John Lynn

Demographics

20y, male

Date of death

2005-01-27

Finding date

2009-12-31

Cause of death

hypoxic encephalopathy

AI-generated summary

Matthew Lynn, aged 20, died from hypoxic encephalopathy after sustaining head injuries in a motor vehicle collision. While hospitalised in ICU, his endotracheal tube (ETT) became displaced around 12:20am on 23 January 2005, likely moving upward initially with the cuff at or above the larynx. A junior registrar (Dr B.) performed laryngoscopy and incorrectly concluded the tube was correctly positioned. Despite clinical evidence of malposition—bile emerging from the ETT, falling oxygen saturations despite 100% oxygen, and later abdominal distension—the incorrect assessment was accepted by another registrar (Dr J.). Vecuronium paralysis was administered based on this false premise, eliminating the patient's own breathing efforts. Cardiac arrest followed. Only at 1:25am, 65 minutes later, was the tube found to be in the oesophagus and replaced. Severe hypoxic brain injury resulted; he died 27 January. The coroner found the death preventable through culture of cross-checking intubation, use of capnography, and prompt re-evaluation when clinical signs suggested malposition.

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Specialties

intensive careanaesthesiaemergency medicine

Error types

diagnosticcommunicationsystem

Drugs involved

propofolfentanylmidazolamvecuroniumatropineadrenaline

Clinical conditions

head injuryblunt force head traumahypoxiahypoxic encephalopathyhypoxic brain injurycerebral oedemabrain deathcardiac arrestpneumothoraxstaphylococcal chest infectionaspiration of gastric contents

Procedures

endotracheal intubationlaryngoscopybag-mask ventilationcardiopulmonary resuscitationleg fracture surgeryskin grafting

Contributing factors

  • endotracheal tube displacement from trachea to oesophagus
  • failure to detect tube malposition despite clinical signs
  • failure to perform capnography
  • failure to re-check tube position when clinical uncertainty existed
  • administration of paralytic agent (vecuronium) based on false premise of correct tube positioning
  • delayed recognition of abdominal distension indicating oesophageal intubation
  • reliance on single clinician's laryngoscopy without cross-checking
  • prolonged period of inadequate ventilation and oxygenation

Coroner's recommendations

  1. Minister for Health to draw this case to the attention of Chief Executive Officers of all public hospitals in South Australia to establish a culture of cross-checking endotracheal tube positioning by laryngoscopy in situations involving clinical uncertainty
  2. Minister for Health to cause steps to be taken within all public hospitals in South Australia to institute capnography on a continuous basis in respect of all intubated patients, especially in situations involving paralytic agents
  3. Minister for Health to cause steps to be taken within all public hospitals in South Australia to ensure capnography is utilised in all situations involving clinical uncertainty as to correct endotracheal tube positioning
  4. Minister for Health to cause steps to be taken within all public hospitals in South Australia to encourage use of laryngoscopy to check endotracheal tube positioning immediately following administration of a paralytic agent
  5. Minister for Health to draw these findings and recommendations to the attention of Chief Executive Officers of all private hospitals in South Australia for consideration
  6. Findings and recommendations to be drawn to the attention of the Joint Faculty of Intensive Care Medicine (Australian and New Zealand College of Anaesthetists and Royal Australasian College of Physicians) for consideration and necessary action
  7. Amendment of Joint Faculty of Intensive Care Medicine guidelines paragraph 9.3.9 to include stipulation that capnography should be used to confirm tracheal placement of endotracheal tube during its use as well as immediately after insertion
Full text
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