Finding into death of Delta Diawo Poke
Deceased
Delta Diawo Poke
Demographics
42y, female
Date of death
2011-12-18
Finding date
2016-05-26
Cause of death
Global cerebral ischaemia in a setting of anaesthesia
AI-generated summary
A 42-year-old woman died from global cerebral ischaemia following cardiac arrest during anaesthesia for a late-term termination of pregnancy. The anaesthetist, Dr McAllister, failed to obtain or ensure a functioning pulse oximeter reading before induction of anaesthesia, despite difficulty obtaining saturation readings while the patient was awake. He administered propofol, fentanyl, and midazolam without baseline vital signs or airway protection, creating significant risk of hypoxaemia. The surgeon, Dr S., was not alerted to these difficulties and was unable to visualise patient monitors. Death was preventable with appropriate pre-anaesthetic assessment, functioning pulse oximetry monitoring before and during anaesthesia, and proper airway management. Systemic issues at the facility included poor documentation, inadequate staff training, and absence of continuous cardiac monitoring in the operating theatre.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Contributing factors
- Failure to obtain baseline oxygen saturation reading before anaesthesia
- Failure to ensure pulse oximeter was functioning
- Failure to obtain full vital signs prior to anaesthetic induction
- No pre-anaesthetic assessment conducted
- Administration of anaesthetic drugs (propofol, fentanyl, midazolam) without adequate monitoring
- Unprotected airway
- Lack of communication between anaesthetist and surgeon regarding monitoring difficulties
- Surgeon unable to visualise patient monitoring parameters
- Absence of continuous cardiac monitoring in operating theatre
- Inadequate documentation of anaesthetic management
- Poor record-keeping at the facility
Coroner's recommendations
- The JCCA should review the training required by general medical practitioners for attaining accreditation to practice as a GP Anaesthetist
- The JCCA should implement a compulsory continuing professional development (CPD) scheme for GP Anaesthetists
- The JCCA should link ongoing or triennium accreditation to practice as a GP Anaesthetist only on completion of compulsory CPD points as determined within the stated period
- The JCCA should investigate and examine the feasibility of introducing a formal but accessible mentoring program for GP Anaesthetists
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