Coroner's Finding: de-identified OV
Demographics
1y, male
Date of death
2022-05-07
Finding date
2023-11-14
Cause of death
hypoxic brain damage due to laryngeal obstruction from foreign body (metal screw)
AI-generated summary
An 11-month-old boy died from hypoxic brain damage following aspiration of a 2cm metal screw that lodged in his larynx. The child was left briefly unsupervised at home when he ingested the screw and began choking. Parents and neighbours initiated CPR. Ambulance paramedics arrived within 6 minutes but struggled to visualize and remove the screw due to blood and vomit in the airway. An intensive care paramedic arrived and successfully removed the screw via laryngoscopy with Magill's forceps at 24 minutes post-obstruction, then intubated the child. Despite resuscitation efforts, the prolonged hypoxia (minimum 24 minutes) caused irreversible cerebral damage. The coroner found paramedic care was appropriate and professional. Key clinical lesson: foreign body airway obstruction in infants can rapidly cause fatal hypoxic brain injury; early airway visualization and removal are critical, and the time interval from obstruction to definitive airway management is the crucial determinant of outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Contributing factors
- foreign body aspiration (metal screw)
- laryngeal obstruction
- prolonged airway obstruction (minimum 24 minutes before removal)
- difficulty visualizing airway due to blood and vomit
- delayed definitive airway management
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