Deceased
XH
Demographics
46y, male
Coroner
Deputy State Coroner Caitlin English
Date of death
2019-04-20
Finding date
2021-10-25
Cause of death
Hypoxic ischaemic brain injury complicating a cardiac arrest during anaesthetic induction for an elective inguinal hernia repair
AI-generated summary
A 46-year-old male underwent elective inguinal hernia repair at a private hospital. During anaesthetic induction, he experienced cardiac arrest. The endotracheal tube (ETT) was visualized passing through the vocal cords, but likely became dislodged, kinked, or obstructed. Early clinical signs were misattributed to anaphylaxis or bronchospasm rather than ETT malposition. The ETT position was not visually rechecked until late in the resuscitation, at which point it was found in the oesophagus. By then, severe hypoxic brain injury had occurred, leading to brain death. Key lessons: maintain high suspicion for airway malposition despite initial visualization; rely on capnography waveform as the most reliable confirmation; avoid anchoring bias on initial diagnostic impressions; visually recheck ETT position early in unexplained deterioration; ensure capnography is immediately available and its absence or abnormality triggers systematic verification.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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