Inquest into death of Andrea LESTER

49y · Female·Hypoxic brain injury related to tracheostomy complications in form of airway occlusion from sputum plugging and/or tube dislodgment

Andrea Lester, age 49, suffered a subarachnoid haemorrhage from a PICA aneurysm in March 2018 with delayed diagnosis. Following complex neurosurgery causing Wallenberg syndrome, she required tracheostomy for bulbar dysfunction. On 13 June 2018, she suffered cardiorespiratory arrest due to airway occlusion from sputum plugging and/or tube dislodgment while a tracheostomy cap (not the planned speaking valve) was in place. The cap was applied without team authorization by nursing staff who were not adequately trained to distinguish between equipment types. Critical systemic failures included: uncoordinated multidisciplinary management without senior medical bedside involvement; failure to recognize Ms Lester had not met safe decannulation criteria despite ongoing heavy secretions and recent chest infection; poor documentation and handover; inadequate staff education on tracheostomy management due to infrequency of such patients on the ward; and failure to escalate after a near-fatal incident on 6 June involving the same equipment confusion. The coroner found this death potentially preventable through proper team coordination, staff training, senior medical oversight, and adherence to existing clinical policies.