Inquest into the death of Adam Fitzpatrick

20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and prolonged cardiac arrest from bilateral tension pneumothorax

Adam Fitzpatrick, a 20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged. Clinical staff performed unnecessary bronchoscopy, misinterpreting findings as a partial obstruction rather than recognising complete dislodgement. Critically, the tube should have been removed and replaced immediately when a suction catheter could not be passed, but this did not occur for approximately 46 minutes. Staff attempted blind bougie instrumentation and bag-valve-mask ventilation through a displaced tube, causing bilateral tension pneumothoraces. Delays in emergency airway management, failure to use laryngeal mask airway, and failure to perform timely finger thoracostomy significantly contributed to Adam's 46-minute cardiac arrest, hypoxic brain injury, and death. The rigid adherence to an inadequate airway plan, absence of effective team communication, failure to exercise clinical judgment despite clear clinical indicators, and deficient crisis resource management all contributed to this preventable death.