A coronial inquest into the death of a Yolngu mother has uncovered a string of catastrophic failures in the healthcare she received at a Darwin hospital.
Ms Guyula, a mother of four children and grandmother to seven, was living in the remote community of Gapuwiyak in remote northeast Arnhem Land in the Northern Territory in 2022.
Known to be an "excellent fisher" who loved camping and taught her daughters to weave, she had reluctantly travelled to the capital for what was meant to be a routine procedure in March that year.
But the inquest, led by Northern Territory Coroner Elisabeth Armitage, revealed Ms Guyula went five minutes without sufficient oxygen after staff put a breathing tube down her oesophagus instead of her wind pipe.
The coroner heard that the critical error went unrecognised by multiple staff.
A 'never event'
The coroner heard in the inquest that oesophageal intubations can happen to any anaesthetist.
However, the failure to recognise the error, and the delay in rectifying it, is considered a 'never event': a mistake so grave it should never have happened, due to precautions that are taken to ensure they never do.
The coroner heard all staff believed they had successfully inserted the breathing tube due to signs of chest fall, "misting" in the tube, and what they incorrectly assumed was a device monitoring her carbon dioxide output.
NSW-based intensive care and aesthetics specialist Ian Seppelt told the coroner he was "dumbfounded" that multiple staff did not realise the device they thought was monitoring her air flow was actually a muscle movement monitor.
The coroner heard that the "gold standard" for intubations was for patients to be connected to a carbon dioxide monitor and to have a CMAC device — a breathing tube with a camera attached.
The coroner heard that, at the time of Miss Guyula's treatment, there were just three CMACs across nine operating wards and only two carbon dioxide monitors in the 14 bay recovery ward.
Circumstances leading to admission
From 24 February 2022, Ms Guyula was receiving treatment for a boil on her right buttock from Miwatj Health Clinic in Gapuwiyak.
She was taking antibiotics but the boil was not healing and she was encouraged to go to Royal Darwin Hospital to have the boil drained surgically due to a high risk of serious infection.
Ms Guyula suffered from multiple illnesses, including type 2 diabetes, ischaemic heart disease, cerebrovascular disease, chronic kidney disease, and a past history of rheumatic heart disease.
On 2 March 2022, Ms Guyula and her daughter Maxine flew to Darwin with CareFlight and Ms Guyula was admitted to the emergency department at around 7.30pm.
A string of critical errors
Following the routine surgery the next day, Ms Guyula was taken to the recovery unit where her condition appeared to rapidly deteriorate and it was determined she needed to be re-intubated.
Her operating doctor, Dr Hughes, immediately left the theatre once notified of the complication and found Ms Guyula surrounded by between six to eight medical staff.
Despite being told by staff the re-intubation was successful, Dr Hughes identified the tube had been incorrectly placed in her oesophagus and preformed a second reintubation around five minutes after the error had occured.
Following the second intubation, key errors with her medication were made when a Propofol infusion was not commenced and a Metaraminol infusion that should have ceased, continued.
"I accept that these errors were likely caused by the sustained pressure of the situation and miscommunication in that context," Coroner Elisabeth Armitage said.
In the days following, Ms Guyula was turned on her bed, and her breathing tube (which was inserted during a tracheostomy days earlier) was dislodged, resulting in a sudden loss of ventilation.
A later investigation by NT Health indicated a lack of clear policy guidance on the insertion and management of a tracheostomy may have contributed to this event.
The two separate events on 3 March and 13 March, which resulted in a loss of oxygen to Ms Guyula’s brain, caused permanent brain damage and cardiac arrest, the coroner heard.
Ms Guyula passed away on the 17 March 2022 after her ventilator was turned off.
'Shocked and devastated'
NT Health has openly acknowledged responsibility for the failures that led to Ms Guyula’s death and has updated its policies, procedures and training to address those errors.
Coroner Elisabeth Armitage acknowledged in her findings that carbon dioxide monitors are now at every bedside in the Post-Anesthesia Care Unit (PACU) at Royal Darwin Hospital.
The coroner heard Mis Guyula was loved by her family and they were shocked and devastated when she unexpectedly passed away.
Her daughter Maxine was by her bedside every day in hospital and describes the 15 days she spent in the hospital before her death as a “sad time”.
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