Inquest into the death of C Guyula

49y · Female·Hypoxia due to complications following incision and drainage of a right buttock abscess and inadequate reversal of anaesthetic

A 48-year-old woman with multiple comorbidities (diabetes, COPD, chronic kidney disease, ischaemic heart disease) died following complications of anaesthesia during incision and drainage of a buttock abscess. Critical failures included: inadequate reversal of neuromuscular blockade (Train of Four monitor not calibrated pre-operatively); oesophageal intubation not recognised due to misidentification of an impedance monitor as capnography; delayed detection allowing hypoxia; medication errors (Metaraminol infusion continued, Propofol not commenced); and subsequent tracheostomy dislodgement causing further hypoxic events. The chain of preventable errors resulted in permanent brain damage and death. Key lessons: mandatory Train of Four calibration before blockade administration, capnography in all post-operative areas, C-MAC video laryngoscope availability, improved staff training and communication, and documentation standards.