Acute agitation, sedation, aspiration, Cannot intubate/ventilate – lessons from Coroners cases


Hi folks. There has been a lot of online discussion and debate about FOAMEd recently. Peer review, minimum standards, code of conduct, curriculum even..

To be honest, there has always been FOAMEd for the health profession, particularly emergency care professionals, hospital or prehospital. Its called the Coroner’s court. They publish coronial findings into unexpected deaths, all the time. Sometimes, these involve medical issues related to emergency care.

Each state/territory of Australia has its own Coroner’s court and their findings are publicly available on their respective websites. They are not a medical journal. Not a blog site. Not peer reviewed. They have no curriculum. They have no podcast.  Their work is legislated and mandated. It is enshrined in public open access. It is free..well our taxes pay for their work. Why? Principles of justice and social good. The needs of the many outweigh the needs of the few..that reminds me of a Star Trek line from Kirk and Spock..gee that was an old movie 😉

So FOAMEd is nothing new. The Coroner has been doing it for years. We just dont usually pay it any regular attention as a medical community.

Why not? perhaps because the findings sometimes deal with medical errors, patient safety errors..errors. These terms make us squirm as doctors, nurses, paramedics, respiratory therapists ..we like to think we dont make mistakes;-)

From Death we learn. This is true FOAMEd.

Now I am not saying the following cases contain real examples of medical error. I leave it up to you the reader to decide. The Coroner has made their findings known in each case. But if there is something to learn from each case, in regard to management of agitation, use of acute sedation and choice of sedation, aspiration risk and ultimately management of Cannot intubate/ventilate crisis, maybe that helps you think. It certainly has helped me in preparing for similar cases…and dealing with them.

Coroners finding into 2001 death of Adam Fernandez

Coroners findings into 2007 death of David Lee

Feel free to email me or post comments here if you want to learn the take home messages I have gained from these cases.

9 thoughts on “Acute agitation, sedation, aspiration, Cannot intubate/ventilate – lessons from Coroners cases

  1. Ah, airway again! I do enjoy the Coroner’s reports and learn from them (google shark and South Australia).

    Also some VERY valuable lessons for rural Australia and the clinicians there in other cases – suicide, deteriorating patient (sepsis), transfer and availability of resources (blood products etc) have featured in my State in recent decade.

    Often frustrating that despite Coronial recommendations, no specific action taken place – although recently a ‘deteriorating patient’ project has started in SA, which is good. I think.

    Still waiting for the outcome of the Victoria Kerang train crash Coroner’s report – due last year – Coroner’s office reckons may be later this year..may be some lessons there for use of rural docs in major incidents prior to expert retrieval arrival?

    1. thanks TIm
      I regard the FOAMEd of Coroners office findings to be valuable learning for us all regardless of location, rural or city. Its why I cited one case set in a major city ED and the other in a remote rural hospital.

      As for airway topics..well its obvious I have an interest in them ;-).
      I am not going to make apologies for highlighting issues I think impact on patient care quality and safety, even it it seems repetitive.

      In true spirit of FOAMEd you can take it or leave it.

      Certainly I would not ask Martin Bromiley to stop trying to raise issues of patient safety and care with the medical profession.

      In fact I applaud his tireless efforts…they inspire me.

      1. …Minh, your passion for all things airway and for wanting to raise the bar are inspirational. No doubt about that.

        Me? Am trying to wean from airway obsession….but it may be too hard to resist. Is there some sort of support group?

  2. I’m not sure you can equate the Coroner’s Court with individuals posting educational material on-line. Whilst the Coroner’s Court may not be subject to the same rules of evidence as a criminal trial, there are still rules of natural justice and procedural fairness. Expert witnesses are called to contribute to the opinions formed and there are regulations about the way in which those opinions can be expressed in the publication that ultimately becomes FOAM.

    I would also disagree that the medical community doesn’t pay any regular attention to Coroner’s findings. Whilst I don’t review them in a systematic way myself, relevant coronial cases being flagged within our Department is a fairly common occurrence. I agree that there is a lot to be learned from these cases.

    The Fernandez case appears to highlight issues surrounding the danger of sedating unfasted patients, particularly when other CNS depressants are on board. It was also a case when insertion of an LMA with a gastric port might have been useful when intubation was unsuccessful (although the presence of foodstuff in the trachea & bronchi at autopsy may indicate that the “horse had already bolted” in this regard – still its unknown at what stage this food material entered the lower airway). It’s interesting that none of these points are made note of in the findings.

    The Lee case makes mention of the problem of fixation on intubation rather than other NSA/ESA techniques to establish an airway but appears to make no recommendations to address this. It also makes some unclear statements about the possible causes of an absent ETCO2 trace (citing equipment failure or absent ventilation) without specifying that the absent ventilation might be due to the ETT being in the wrong place (although it does mention this possibility later in the text). Finally the case would appear to raise the issue of the need for the airway to be secured once a deep level of sedation has been achieved (even though that deep sedation may not have been intended or desirable in the first place) but no specific recommendations are made in this regard.

    The Coroner’s findings appear to take a “root cause” approach to the problem rather than addressing other opportunities to intervene and prevent the death once these antecedent adverse events have transpired.

    None of my comments are intended to be a criticism of either the Coroner or the clinicians involved as they are made with only limited access to the facts of the case, the benefit of hindsight & minimal understanding of the specific terms of reference of a Coronial inquiry. They are simply the issues that spring to mind on the basis of the facts presented in the report.

  3. thanks Nic! I always like how you use that huge analytical brain of yours to dissect things!
    In some ways Coronial process of investigation is the ultimate FOAMEd due to a strict process, with minimum standards , conduct regulations and procedure. It even has PEER Review , but some would argue that an expert anaesthetist witness commenting on the airway decision making of a GP or ED physician is not indeed fair PEER review ;-)!

    Of course Coroners miss things as you well point out, or deliberately make no comment or a neutral one. We are not privy to ALL that was said and asked at these inquests unless we were actually present.

    I personally think the Anaesthetic community in Oz, lead by ANZCA AIrway SIG have highlighted the benefit of learning from these coronial findings and in fact they issued a paper a couple of years ago stating that they felt the need for a national coordination or registry of significant coroners findings related to airway management, so that the medical community can learn collectively.

    But my opinion is based on attending a lot of educational meetings for various disciplines and rarely are coronial findings mentioned as points of learning.

  4. Nic I think your point about caution with sedation in the intoxicated patient is an excellent one. I teach this to colleagues and new registrars in prehospital and retrieval medicine as a cardinal rule of retrieval sedation safety.

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