Tube incorrectly placed kills 19mths old girl


A coronial inquest has found the death of a 19-month-old girl at Port Macquarie Base Hospital after an incident during surgery in February 2019 could have been prevented.

The Coroner Derek Lee said anaesthetic team missed a “constellation of signs” that the intubation was incorrectly placed in the oesophagus.

Coroner Lee said there were a number of signs indicating the ETT had been place incorrectly, but staff failed to recognise them.  The oesophageal intubation [incorrectly placed ETT] resulted in sudden deterioration of the girl’s condition,” he said.

“Her heart rate and oxygen saturations decreased to precariously low levels and she went into cardiac arrest.  Despite resuscitation efforts, she could not be revived and was tragically pronounced deceased, only 10 hours after arriving at the wildlife park.”

Port Macquarie Base Hospital is part of the Mid North Coast Local Health District which has apologised to the victim’s family.

Mid North Coast Local Health District Chief Executive Stewart Dowrick said since the incident, appropriate measures have been put in place at Port Macquarie Base Hospital to help prevent another tragedy of this kind.

Read more of ABC Keely Johnson’s report:

MEAG COMMENT:  One would think these ‘appropriate measures’ were already in place.  Why weren’t they?  It was a hospital after all.  Who wants apologies?  Patients want competent staff 100% 24/7.  Another unnecessary tragedy in Australia’s all too many hospital tragedies.  

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