Inquest into the death of Brooke Tiddy

32y · Female·Cardiac arrest due to hypoxia caused by dynamic hyperinflation arising from complications related to subglottic stenosis

A 32-year-old woman with Sponastrime Dysplasia (a rare genetic bone disorder) died during elective bariatric surgery. She had undiagnosed subglottic stenosis (airway narrowing) and tracheobronchomalacia. Critical clinical lessons: (1) Rare or unfamiliar diagnoses require active investigation and specialist referral—Dr K. failed to research Sponastrime Dysplasia or seek pre-operative assessment despite its obvious complexity; (2) Pre-operative anaesthetic assessment days/weeks before surgery, not morning-of, is essential for complex patients—Dr D.'s bedside exam missed the condition because he never read "Sponastrime Dysplasia" on admission forms; (3) Surgeon-anaesthetist communication before admission was absent despite being standard for complex cases; (4) Once intubated, her stenotic airway caused dynamic hyperinflation, leading to cardiac arrest. The autopsy revealed previously undiagnosed severe subglottic stenosis. Earlier recognition would have allowed joint surgical-anaesthetic planning or procedure deferral. Lost opportunities for investigation and communication proved fatal.