Finding into death of Margaret Webber

48y · Female·Aspiration of stomach contents and pneumonia, following cardiac arrest

Margaret Webber, aged 48, with cerebral palsy and diabetes, died from aspiration of stomach contents and pneumonia. She presented to hospital with diabetic ketoacidosis (DKA) and coffee-ground vomit, which raised concern for gastrointestinal bleeding. Clinical management appropriately treated DKA as the primary diagnosis while monitoring for bleeding with serial haemoglobin measurements. A blood transfusion was ordered at 4.45pm when haemoglobin fell to 84g/L, meeting international guideline criteria. However, before transfusion could be administered, Ms Webber vomited and aspirated while clinicians were attempting to insert an arterial line for ICU-level monitoring. The aspiration led to cardiac arrest and death. The coroner found the death was not preventable through earlier transfusion—the clinical decision-making was appropriate given the diagnostic uncertainty, evolving haemoglobin levels, and priority of DKA management. The aspiration event itself was not foreseeable.