Inquest into the Death of Richard Christopher Jankowski

Contributing factors

• Inadequate immediate availability of capnography monitoring in recovery room
• Delayed confirmation of oesophageal intubation due to reliance on breath sounds rather than capnography
• Fibre optic laryngoscope (bronchoscope) not immediately available; when retrieved it malfunctioned
• Failure of emergency call system to reach appropriate professional support beyond anaesthesia department
• Lack of high dependency/ICU bed availability; patient remained in recovery instead of being transferred to ICU pre-operatively
• Progressive post-operative swelling of airway structures in vicinity of epiglottis due to infection and surgical trauma
• Dr T.'s unsuccessful attempts at needle cricothyroidotomy (lacked confidence and familiarity with technique)
• Initial intubation attempt in recovery resulted in oesophageal rather than tracheal placement
• Delay in securing emergency airway; critical time wasted before Dr E. performed successful cricothyroidotomy

Coroner's recommendations

1. Patients who have had infection and surgery in the vicinity of their airways should be monitored as to their O2 saturation levels at all times
2. Patients who have had infection and surgery in the vicinity of their airways should be positioned in proximity to an expired CO2 monitor which is functioning and user-friendly at all times
3. Patients who have had infection and surgery in the vicinity of their airways should be placed in a unit with immediate access to surgical intervention if it becomes necessary until such time as it is clinically likely the infection is under control
4. Airway resources trolley should be relocated to the recovery room in circumstances where there is a high-risk airway compromise patient
5. Emergency call system should reach a wider range of professional skills and support, not just narrow-discipline fields
6. Capnography monitoring should be available and functioning at all times in recovery areas where airway compromise risk exists, not just when a problem arises
7. Fibre optic bronchoscope and video bronchoscope availability should be improved with redirection of funding
8. Training and experience in emergency cricothyroidotomy procedures should be improved for anaesthetists and intensive care registrars