Coroner's Finding: Woolley, Paul James

Contributing factors

• Failure to ensure CPAP use post-operatively despite surgeon and anaesthetist expectations
• Absence of continuous oxygen saturation monitoring
• Undetected hypoxia overnight leading to respiratory arrest
• Lack of specific UPPP clinical pathway; use of generic tonsillectomy pathway instead
• Nursing staff misinformation regarding CPAP safety post-operatively
• Inadequate written post-operative instructions from surgeon
• Assumption that nursing staff would implement CPAP without explicit written direction
• Morbid obesity
• Multinodular goitre
• Heparin-induced thrombocytopenia

Coroner's recommendations

1. Calvary St John's Hospital to fully implement 28 recommendations from its internal review following this death
2. Implementation of specific UPPP clinical pathway (now developed) providing for CPAP use and continuous oxygen saturation monitoring
3. Proper education of nursing staff regarding requirement for CPAP use following UPPP surgery
4. Update of Clinical Patient Observation (Vital Signs) - Adult Policy to ensure appropriate monitoring of post-operative airway surgery patients
5. Explicit written post-operative orders from surgeons regarding CPAP use and oxygen saturation monitoring