Finding into death of Margaret Webber
Deceased
MARGARET WEBBER
Demographics
48y, female
Date of death
2009-07-03
Finding date
2014-05-28
Cause of death
Aspiration of stomach contents and pneumonia, following cardiac arrest
AI-generated summary
Margaret Webber, aged 48, with cerebral palsy and diabetes, died from aspiration of stomach contents and pneumonia. She presented to hospital with diabetic ketoacidosis (DKA) and coffee-ground vomit, which raised concern for gastrointestinal bleeding. Clinical management appropriately treated DKA as the primary diagnosis while monitoring for bleeding with serial haemoglobin measurements. A blood transfusion was ordered at 4.45pm when haemoglobin fell to 84g/L, meeting international guideline criteria. However, before transfusion could be administered, Ms Webber vomited and aspirated while clinicians were attempting to insert an arterial line for ICU-level monitoring. The aspiration led to cardiac arrest and death. The coroner found the death was not preventable through earlier transfusion—the clinical decision-making was appropriate given the diagnostic uncertainty, evolving haemoglobin levels, and priority of DKA management. The aspiration event itself was not foreseeable.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- Diabetic ketoacidosis
- Gastrointestinal bleeding (slow chronic bleed)
- Sepsis and pneumonia
- Aspiration during arterial line insertion attempt
- Compromised pulmonary function from existing infection
- Difficulty obtaining intravenous access due to joint contractures and poor peripheral perfusion
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