WAhospital

Inquest into the Death of Rasmussen

Deceased

Rachael Anne Rasmussen

Demographics

31y, female

Date of death

2003-06-17

Finding date

2007-06-08

Cause of death

cerebral anoxia following attempted intubation pre-surgery in a woman with torticollis

AI-generated summary

Rachael Anne Rasmussen, a 31-year-old mother of three with severe neck deformities (torticollis, dysmorphia, short rigid neck), died on 17 June 2003 from cerebral anoxia following attempted intubation at Joondalup Health Campus. She was admitted for elective left inguinal hernia repair. Dr L., the anaesthetist, administered the intermediate-acting muscle relaxant Atracurium without first establishing that ventilation was possible—a fundamental breach of anaesthetic protocol. Despite his pre-operative assessment noting potential difficult intubation, he proceeded with general anaesthesia and paralysis. Subsequent attempts by multiple senior anaesthetists and the surgeon to establish an airway all failed; the trachea was deviated and could not be located. Resuscitation was unsuccessful. The coroner found the death was preventable, arising by misadventure, and referred Dr L. to the Medical Board of Western Australia. Critical failures included inadequate pre-anaesthetic assessment, failure to obtain prior anaesthetic records showing previous ventilation difficulties, and failure to pursue safer alternatives such as awake intubation. Recommendations addressed communication of anaesthetic difficulties and system improvements to record and share airway problems.

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Specialties

anaesthesiageneral surgeryintensive care

Error types

diagnosticproceduralcommunicationdelay

Drugs involved

atracuriumranitidineomeprazolepropofolsuxamethoniumpethidine

Clinical conditions

torticollisneck flexion deformitydysmorphiatracheal deviationgoitrescoliosisasthma (mild)difficult airwaycerebral anoxia

Procedures

intubationlaryngeal mask airway insertionattempted cricothyrotomyattempted fibreoptic intubationattempted jet ventilationattempted emergency tracheostomy

Contributing factors

failure to establish ventilation prior to administering muscle relaxant
inadequate pre-anaesthetic assessment by Dr L.
failure to obtain prior anaesthetic records demonstrating previous ventilation difficulties
failure to recognize obvious anatomical difficulties from visual inspection
inappropriate choice of general anaesthesia over regional block or awake intubation
tracheal deviation and mechanical airway obstruction
enlarged thyroid gland
severe neck deformity and rigidity preventing surgical access

Coroner's recommendations

Representatives of Anaesthesia Western Australia and the Health Department meet to review reporting guidelines and to consider the level of recording of anaesthetic difficulties in the present TOPAS system with a view to improving the consistency with which anaesthetic difficulties are recorded in the system and to include entries in the TOPAS system for patients where difficulty has been experienced with ventilation during anaesthesia and in cases where intubation difficulties are likely to arise in the future.
The Department of Health give urgent consideration to reviewing the present system relating to access to the Med-Alert system, currently operating as part of TOPAS in the public hospital system, so that it can be available to privately operated hospitals and to all anaesthetists in the state so that potential life saving information is readily available and can be acted upon.
Anaesthetists be encouraged to adopt a practice of reporting difficulties with the ventilation or intubation of patients during anaesthesia to their referring physician and the patient in writing and to place a copy of the letter in the patient's medical record.

Full text

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