Finding into death of Madeleine Therese Sobb

25y · Female·Airway obstruction complicating laryngeal dilation for the treatment of subglottic stenosis in a woman with spondylo-epi-metaphyseal dysplasia

Ms Sobb, a 25-year-old woman with spondylo-epi-metaphyseal dysplasia causing severe airway abnormalities and subglottic stenosis, died from airway obstruction following laryngeal dilation. She was admitted to ICU with asthma exacerbation from respiratory infection, then transferred to a general ward on 20 May 2015. Critical failures included: inadequate ICU-to-ward handover lacking documentation of adrenaline nebuliser use and airway management plan; missing medical review following discharge and after adrenaline nebuliser administration at midnight; non-compliance with four-hourly observation policy (only recorded at 2400H and 0530H); and insufficient documentation of staff communications. Although deterioration may have been precipitous, earlier medical assessment following the adrenaline nebuliser administration—which required doctor notification per the prescription—could have enabled earlier recognition of airway compromise. The hospital implemented substantial improvements post-inquest including mandatory medical review after adrenaline nebuliser administration, improved discharge checklists, and enhanced tracking of recently-discharged ICU patients.