WAhospital

Inquest into the Death of Richard Christopher Jankowski

Deceased

Richard Christopher Jankowski

Demographics

39y, male

Date of death

2001-02-20

Finding date

2003-08

Cause of death

Hypoxic brain injury due to respiratory obstruction following surgery for dental abscess with cellulitis

AI-generated summary

Richard Christopher Jankowski, a 39-year-old man, died from hypoxic brain injury due to respiratory obstruction following emergency surgery for a dental abscess with cellulitis. After initial treatment with antibiotics, he underwent incision and drainage at Royal Perth Hospital. He was extubated uneventfully and appeared to recover well in the recovery room. However, approximately 2 hours post-operatively, progressive airway swelling developed rapidly, causing complete obstruction. The initial re-intubation attempt was oesophageal rather than tracheal, a critical error not immediately recognised due to apparent breath sounds and non-functioning capnography. Significant time elapsed before this was confirmed. Dr T.'s subsequent attempts at cricothyroidotomy were unsuccessful. Only when senior ICU consultant Dr E. performed the emergency cricothyroidotomy was the airway secured, but irreversible hypoxic brain damage had occurred. The coroner found the death resulted from systems failure: inadequate equipment availability in recovery (capnography, fibre optic bronchoscope), and lack of appropriate immediate professional support for a high-risk airway emergency. The coroner found the death arose by misadventure and made recommendations for equipment placement, monitoring protocols, and improved emergency response systems.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

anaesthesia general surgery oral and maxillofacial surgery ENT surgery intensive care emergency medicine

Error types

procedural communication system delay

Drugs involved

propofol morphine lidocaine sevroflurane amoxicillin paracetamol/codeine procaine penicillin metronidazole benzyl penicillin adrenaline atropine

Clinical conditions

dental abscess with cellulitis odontogenic infection with cervical extension airway obstruction post-operative swelling (laryngeal and epiglottal oedema)oesophageal intubation respiratory obstruction hypoxic brain injury cardiorespiratory arrest mixed metabolic and respiratory acidosis

Procedures

incision and drainage of dental abscess intubation (initial in theatre; re-intubation attempts in recovery)bag-mask ventilation cricothyroidotomy (attempted by dr thornton, successfully performed by dr edibam)laryngeal mask airway (lma) insertion tracheostomy (formal, performed after airway restoration)

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

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
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
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
Airway resources trolley should be relocated to the recovery room in circumstances where there is a high-risk airway compromise patient
Emergency call system should reach a wider range of professional skills and support, not just narrow-discipline fields
Capnography monitoring should be available and functioning at all times in recovery areas where airway compromise risk exists, not just when a problem arises
Fibre optic bronchoscope and video bronchoscope availability should be improved with redirection of funding
Training and experience in emergency cricothyroidotomy procedures should be improved for anaesthetists and intensive care registrars

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