Finding into death of Delta Diawo Poke

42y · Female·Global cerebral ischaemia in a setting of anaesthesia

A 42-year-old woman died from global cerebral ischaemia following cardiac arrest during anaesthesia for a late-term termination of pregnancy. The anaesthetist, Dr McAllister, failed to obtain or ensure a functioning pulse oximeter reading before induction of anaesthesia, despite difficulty obtaining saturation readings while the patient was awake. He administered propofol, fentanyl, and midazolam without baseline vital signs or airway protection, creating significant risk of hypoxaemia. The surgeon, Dr S., was not alerted to these difficulties and was unable to visualise patient monitors. Death was preventable with appropriate pre-anaesthetic assessment, functioning pulse oximetry monitoring before and during anaesthesia, and proper airway management. Systemic issues at the facility included poor documentation, inadequate staff training, and absence of continuous cardiac monitoring in the operating theatre.