McVey, Oliver Steven

67y · Male·Complicated endotracheal tube insertion due to or as a consequence of recent closure of patent ductus arteriosus; death occurred due to lack of sufficient oxygenation during attempted re-intubation

Oliver Steven McVey, a premature twin born at 31 weeks gestation weighing 1036g, died from complications of endotracheal tube re-insertion at 67 days of age. Following successful surgical ligation of a patent ductus arteriosus (PDA), Oliver developed ventilation difficulties in the immediate post-operative period. A 3.0mm endotracheal tube (ETT) was selected for intubation; the coroner noted guidelines recommended 3.5mm for babies over 2kg. Oliver deteriorated with rising CO2 levels despite ventilation changes. At 3:31am on day 2 post-op, blood gas analysis revealed critical ventilation failure (pH 6.94, PCO2 145mmHg). Dr L. elected to re-intubate with a larger 3.5mm tube to address an air leak, but the procedure proved extremely difficult, taking approximately 25-35 minutes with multiple failed attempts by three doctors. Oliver suffered prolonged hypoxia (estimated 15-25 minutes insufficient oxygenation), arrested, and could not be resuscitated. Key lessons: early consideration of larger ETT sizing based on weight, vigilant monitoring of rising CO2 with timely intervention, appropriate ventilator selection (Draeger Babylog 8000 inadequate in HFOV mode for babies >2kg), and availability of alternative airway devices such as laryngeal mask airways.