Finding into death of Alma Lynette Honeychurch

76y · Female·Ludwig's angina

A 76-year-old woman with Ludwig's angina presented to urgent care with facial swelling and fever. She was appropriately diagnosed and arrangements made for transfer to a tertiary centre. However, staff failed to recognise the risk of rapid airway compromise despite documented clinical deterioration (increased noise in breathing, worsening swelling, difficulty swallowing). Escalation to senior staff and appropriate communication did not occur. Transfer was arranged via standard ambulance rather than the specialised retrieval service (ARV), which was indicated for this complex, time-critical case. The patient developed acute airway obstruction during transfer, suffered cardiac arrest and hypoxic brain injury. Key lessons: Ludwig's angina requires recognition of airway compromise risk (may not present with stridor), urgent escalation protocols, and appropriate retrieval coordination for critically unwell patients from rural centres.