Beverly ann murphy finding & recommendations 0701 08

70y · Female·Hypoxic/Ischaemic Encephalopathy consequent upon Cardiorespiratory Arrest and Compromised Airflow through Dislodged Tracheostomy

Beverly Ann Murphy, 70, underwent hysterectomy for endometrial carcinoma on 2 April 2008 at Royal Hospital for Women. The complex surgery was complicated by iatrogenic small bowel perforations. Post-operatively, wound dehiscence and bowel obstruction developed, requiring return to theatre on 12 April for repair, though perforations were not initially recognized. Further surgery on 18 April managed fistulae. A tracheostomy was inserted 24 April at Prince of Wales Hospital. That evening, the tracheostomy tube became dislodged during patient turning. Recognition of airway compromise was delayed approximately 7 minutes, and calling for medical assistance was further delayed. Restoration of airway took approximately 14 minutes, resulting in 20-30 minutes of hypoxia. This caused hypoxic-ischaemic encephalopathy and multi-organ failure. Death occurred 28 April 2008. Failures included radiological misinterpretation, delayed surgical decision-making, nursing delays in escalation, and systems failures in equipment availability.