Inquest into the Death of Rasmussen

31y · Female·cerebral anoxia following attempted intubation pre-surgery in a woman with torticollis

Rachael Anne Rasmussen, a 31-year-old mother of three with severe neck deformities (torticollis, dysmorphia, short rigid neck), died on 17 June 2003 from cerebral anoxia following attempted intubation at Joondalup Health Campus. She was admitted for elective left inguinal hernia repair. Dr L., the anaesthetist, administered the intermediate-acting muscle relaxant Atracurium without first establishing that ventilation was possible—a fundamental breach of anaesthetic protocol. Despite his pre-operative assessment noting potential difficult intubation, he proceeded with general anaesthesia and paralysis. Subsequent attempts by multiple senior anaesthetists and the surgeon to establish an airway all failed; the trachea was deviated and could not be located. Resuscitation was unsuccessful. The coroner found the death was preventable, arising by misadventure, and referred Dr L. to the Medical Board of Western Australia. Critical failures included inadequate pre-anaesthetic assessment, failure to obtain prior anaesthetic records showing previous ventilation difficulties, and failure to pursue safer alternatives such as awake intubation. Recommendations addressed communication of anaesthetic difficulties and system improvements to record and share airway problems.