Inquest into the death of Shirley Elizabeth Haggett

78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchoscopy) due to facial melanoma excision under high-flow nasal oxygen and sedation

78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). The hospital was licensed only for ASA 1-3 patients. The anaesthetist administered high-flow, high-concentration oxygen for over 2 hours, which in a CO2 retainer caused severe hypercarbia and hypercarbic narcosis. Post-operatively, the patient remained obtunded. Despite concerning vital signs (respiratory rate >30, low oxygen saturations), the anaesthetist did not arrange immediate ICU transfer, instead planning to monitor for another hour. The patient aspirated before transfer could be arranged. She deteriorated despite ICU admission and multi-organ failure developed. Key failures: (1) admission of ASA 4 patient to inappropriate facility; (2) inadequate pre-operative assessment of respiratory status; (3) use of high-flow oxygen in CO2 retainer; (4) failure to recognise deterioration post-operatively and arrange timely ICU transfer; (5) systemic failures in escalation protocols at the day hospital.