Coroner's Finding: PAHL-CADMAN Emma Rose

20y · Female·cardiac dysrhythmia/arrest in a 20 year old Down's Syndrome female following abdominal surgery on a background of underlying ventricular septal defect

A 20-year-old woman with Down syndrome and Eisenmenger syndrome (cyanotic heart disease with ventricular septal defect) was admitted with abdominal obstruction. After appropriate diagnostic workup, laparotomy was performed for small bowel obstruction caused by a swallowed examination glove. She died postoperatively from cardiac dysrhythmia. Critical lapses included: anaesthesia delivered by registrar without senior consultant present despite extreme anaesthetic risk; failure to provide intensive monitoring (ECG, continuous oximetry) post-operatively despite preoperative oxygen saturation of 48% and known severe cardiac disease; absence of specialist cardiac input despite availability; and placement on general ward rather than ICU. Measures that might have prevented death included low ventilation pressures, inhaled nitric oxide to reduce pulmonary pressures, high-dependency/ICU admission with continuous monitoring, and consultant anaesthetist supervision.