Inquest into the death of D H

56y · Male·Hypoxia and cardiac arrest with contributing conditions of Ischaemic Heart Disease, Diabetes Mellitus and Morbid Obesity

A 56-year-old man with diabetes, ischaemic heart disease, morbid obesity, and an implanted defibrillator underwent minor toe debridement surgery. The anaesthetist failed to conduct an adequate pre-operative assessment, unaware of the defibrillator despite it being documented. Inappropriate anaesthesia (laryngeal mask with total intravenous propofol) was used for this high-risk patient. During surgery, the patient experienced prolonged hypoxia with severe oxygen desaturation (53–78%), bradycardia (heart rate 26–40/min), and hypertension, none adequately recognised or managed. Cardiac arrest occurred; despite resuscitation, the patient suffered irreversible hypoxic brain injury and died. The coroner found the death preventable due to failures in pre-operative assessment, choice of anaesthetic technique, and intra-operative monitoring and response. Systemic improvements including enhanced pre-operative protocols, high-risk patient flagging, and electronic record integration have since been implemented.