Inquest into the death of Bruce HODGES

78y · Male·cardiorespiratory failure due to complications of tracheal stenosis

Bruce Hodges, a 78-year-old man with a 20-year-old tracheostomy following laryngeal cancer surgery, presented to hospital with progressive shortness of breath and tracheal stenosis. Over 48 hours of admission, his respiratory rate fluctuated between normal and elevated levels despite a critical 4mm airway narrowing. Key clinical lessons: (1) Altered vital sign calling criteria were inappropriately implemented and inadequately reviewed; (2) Respiratory observations were inconsistently recorded, missing opportunities for escalation; (3) The critical airway narrowing warranted closer monitoring and potentially transfer to higher-level care; (4) An arterial blood gas test should have been performed to assess carbon dioxide retention; (5) Specialist review by respiratory and ICU teams did not occur within specified timeframes; (6) Communication with family about management concerns was inadequate. The hospital has since implemented electronic medical records, REACH protocols, and improved escalation procedures to prevent similar preventable deaths.