Inquest into the Death of Waretini

46y · Male·Upper airway obstruction due to acute tonsillitis with laryngeal oedema and haemorrhagic abscess

A 46-year-old man with acute tonsillitis complicated by upper airway obstruction died at Cunderdin District Hospital. He presented with severe pharyngitis on 5 September 2002, was admitted to Kellerberrin Memorial Hospital on 6 September, and improved initially on antibiotics. On 7 September morning, the treating GP (Dr B.) changed antibiotics due to inadequate response, then left town without arranging handover of care or follow-up supervision with another accessible medical practitioner. The patient deteriorated with elevated respiratory rate and agitation; concerned nursing staff encouraged transfer to Cunderdin District Hospital. En route, the patient became unconscious from upper airway obstruction, arrived unresponsive, and could not be resuscitated despite aggressive efforts including intubation. Post-mortem revealed severe laryngeal oedema with right-sided haemorrhagic abscess and pulmonary oedema. The coroner found the death arose by natural causes but identified a critical error of judgement: leaving a patient with risk of rapid airway obstruction without provision for emergency medical supervision was inappropriate, particularly in a remote setting.