R - Non-inquest findings

0y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distress requiring intubation and ventilation, complicated by cardiorespiratory arrest of unknown cause, following cleft palate repair surgery

A 10-month-old boy died following elective cleft palate repair surgery complicated by post-operative respiratory distress and subsequent cardiorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pulmonary oedema requiring intubation. During PICU management, multiple opportunities were missed to verify endotracheal tube positioning: continuous capnography was disconnected during resuscitation, abdominal distension suggesting possible oesophageal intubation was not adequately investigated, and the tube's position was never directly visualized despite clinical concerns. The tube eventually migrated to the oesophagus. Key lessons: implement continuous capnography for all intubated patients, verify tube position with multiple assessment methods (not auscultation alone), investigate gastric distension as a sign of tube malpositioning, maintain capnography during manual ventilation and CPR, and ensure clear airway role assignment during resuscitations.