Finding into death of Cherie Virginia Pearl Guest

61y · Female·Diffuse alveolar damage in a woman with restrictive lung disease following cataract surgery

A 61-year-old woman with severe restrictive lung disease, obesity, cardiac failure, and diabetes underwent cataract surgery at a private day surgery centre on 13 August 2018. She was unable to lie flat and became hypoxic (oxygen 60%) during the first part of the procedure. Despite this decompensation, the second part proceeded, requiring intubation for acute pulmonary oedema. She died five days later from diffuse alveolar damage. The coroner found the surgery was inappropriate at a day centre without critical care facilities for an ASA-4 (high-risk) patient. The surgeon failed to properly assess her fitness, the anaesthetist did not clearly refuse consent, and the hospital CEO failed to enforce admission criteria. Poor communication, inadequate monitoring, and lack of informed consent contributed to a preventable death.