A recent coronial inquest into the death of an Indigenous woman at Royal Darwin Hospital has uncovered a devastating “chain of failures” that led to her passing following routine surgery. The report, released by Northern Territory Coroner Elisabeth Armitage, examined the circumstances surrounding the death of C Guyula, a 48-year-old woman from the Arnhem Land community of Gapuwiyak, who died in the intensive care unit (ICU) on March 17, 2022, after a seemingly straightforward procedure to remove a large boil. The findings highlight critical human errors and systemic issues within the hospital’s post-anaesthetic care unit (PACU) and broader resourcing concerns.
The inquest revealed a series of significant medical oversights, beginning with the failure to attach a Train of Four (TOF) monitor, a device crucial for assessing the effectiveness of muscle relaxants like Atracurium, before Ms Guyula’s surgery commenced. When the TOF monitor was eventually attached, it was not calibrated correctly, significantly increasing the risk of inaccurate readings.
Featured snippet paragraph: The answer to what went wrong in the death of C Guyula at Royal Darwin Hospital lies in a series of critical human errors and equipment mismanagements. These included failing to calibrate a TOF monitor, incorrectly placing an endotracheal tube during re-intubation, and misplacing a syringe driver for a Metaraminol infusion, all contributing to a catastrophic chain of events.
Following the surgery, Ms Guyula became unresponsive and struggled to breathe, symptoms attributed to an incomplete reversal of the anaesthetic. This led to a re-intubation attempt where the endotracheal tube was mistakenly placed in her oesophagus instead of her trachea, a “never event” according to senior anaesthetist Elystan Hughes. The delay in correcting this life-threatening error resulted in prolonged oxygen deprivation.
Further compounding the situation, a syringe driver containing Metaraminol, administered to raise Ms Guyula’s blood pressure, was placed on her bed rather than on a pole, a standard safety measure. This led to an uncontrolled infusion that pushed her blood pressure to alarming levels before it was discovered and stopped.
Ms Guyula remained in a coma for two weeks before her death, leaving her extensive family devastated. Her family’s presence at the inquest underscored their deep need to understand the sequence of events that led to such a tragic outcome.
Coroner Armitage’s report has put forth three key recommendations aimed at preventing similar tragedies. These include mandatory calibration of TOF monitors, the implementation of standardized anaesthesia record-keeping schedules, and the permanent placement of a C-MAC video laryngoscope in the PACU to aid in accurate intubations.
Evidence presented at the inquest suggested that the C-MAC, a common tool in hospitals in the United States and United Kingdom, was not consistently utilized at Royal Darwin Hospital due to perceived resource limitations. Anaesthetist Bernadette Wilks described RDH as “resource poor” and expressed reservations about using the C-MAC unless deemed absolutely essential.
Additionally, the inquest highlighted a failure to use end-tidal capnography, a vital tool for confirming correct tracheal intubation, during Ms Guyula’s re-intubation. This critical diagnostic was confused with an impedance monitor, further contributing to the incorrect tube placement.
Despite these shortcomings, the report notes that capnographs have since been fitted to every bed in the PACU, and nurses have received training on their use. NT Health has acknowledged responsibility for the “catastrophic chain of failures” that resulted in Ms Guyula’s death.
The Royal Darwin Hospital inquest into the death of C Guyula serves as a stark reminder of the importance of meticulous medical practice, adequate resourcing, and robust patient monitoring protocols. The recommendations put forth by the coroner are crucial steps towards ensuring patient safety and preventing future preventable deaths within the healthcare system.
The family of Ms Guyula has expressed their profound grief and their desire for accountability, seeking to understand how such a preventable series of errors could occur. The inquest’s findings are a call to action for healthcare providers to review and strengthen their procedures and training.
