Some of the most powerful lessons I find are from the coroners websites and inquest findings.
Here is a 2012 finding from the Victorian coroner
Lesson : Confirm tracheal intubation using objective methods – capnography or real time bedside USS .
Failure to intubate happens all the time. But failure to oxygenate should never be a sin of omission.
In the words of one of the ICU consultants involved in the inquest, Oxygenation is the key not intubation.
Nasal Cannula Oxygenation may have helped in this case, even with unrecognised oesophageal intubation. It may also not have helped by masking effects of incorrect tube placement and delaying correction.
These coroners findings and similar ones are a matter of public record and appear on official websites for general digestion.
They are never pleasant or positive things to read for all parties and I take no joy nor smugness from discussing them here.
But I hope to honour the tragedy
This is not about assigning blame. It is about learning from the past, making things safer.
This case could have happened to any of us.
I truly believe from death we can learn and become better at what we do.
This is the responsibility we take on in our jobs providing emergency care no matter where.
This is the discipline.