Inquest into the death of Judith Smart

66y · Female·Hypoxic-ischaemic encephalopathy

A 66-year-old woman with COPD, obstructive sleep apnoea, and obesity underwent routine knee surgery at Royal Darwin Hospital. Post-operative care was inadequate. Despite dropping oxygen saturations to 88% when sedated and requiring frequent rousing, she was discharged from PACU with modified oxygen saturation criteria and relocated to a general ward with minimal nursing observation. A morphine PCA was prescribed without adequate consideration of her respiratory risks. She suffered cardiac arrest from hypoxia approximately two hours post-discharge. Clinical lessons: patients with OSA, COPD, and obesity require continuous close observation post-operatively; oxygen saturation modifications require thorough clinical review; CPAP machines must be immediately available; high-risk patients need specialized monitoring units, not general wards; end-of-life care communication and symptom management require explicit planning.