Inquest into the death of Emiliana OBUSAN

1y · Female·unrecognised oesophageal intubation

A 19-month-old girl died from unrecognised oesophageal intubation during anaesthesia for finger laceration repair. The anaesthetic team failed to recognise multiple clinical indicators of tube misplacement: absence of persistent end-tidal CO2 waveforms, persistent air leak despite cuff inflation, coarse upper airway sounds, and gastric distension. These signs should have prompted ETT repositioning verification. The team became fixated on alternative diagnoses (bronchospasm, anaphylaxis) despite inadequate evidence, in a stressful environment. The coroner found the death preventable—appropriate recognition of the reversible cause would have prompted removal and reinsertion of the endotracheal tube, likely preventing death. Key lessons: verify ETT placement using capnography, recognise that misplaced tubes can still provide some ventilation in infants, synthesise all clinical indicators rather than fixating on one diagnosis, and consider mandatory paediatric anaesthesia guidelines for regional hospitals.