Finding into death of Delta Diawo Poke

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

1. The JCCA should review the training required by general medical practitioners for attaining accreditation to practice as a GP Anaesthetist
2. The JCCA should implement a compulsory continuing professional development (CPD) scheme for GP Anaesthetists
3. 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
4. The JCCA should investigate and examine the feasibility of introducing a formal but accessible mentoring program for GP Anaesthetists