Coroner's Finding: GORDON Sally Anne

20y · Female·Cerebral anoxia consequent upon a severe acute asthmatic event

Sally Anne Gordon, a 20-year-old with a 14-year history of severe brittle asthma, presented to Mount Gambier Hospital on 26 November 2000 with acute severe asthma unresponsive to initial treatment. After appropriate emergency management including oxygen, adrenaline and hydrocortisone, she was transferred to the High Dependency Unit where intubation became necessary. Dr N., a medical officer with 10-11 years post-graduate experience, chose pancuronium 4mg as a paralysing agent rather than suxamethonium. Expert analysis found this choice suboptimal but not causative of death. During two intubation attempts, vomiting/regurgitation occurred obscuring the vocal cords. The anaesthetist Dr G. successfully intubated on arrival but Ms Gordon arrested shortly after, suffering severe hypoxic brain damage from which she died at Royal Adelaide Hospital. The death reflects the inherent difficulties and poor prognosis in status asthmaticus rather than negligent care.