A woman died when a breathing tube was inserted into her food pipe instead of her wind pipe for 17 minutes during an operation surgery at an Auckland hospital.
She suffered an unsurvivable brain injury.
The Health and Disability Commissioner (HDC) has criticised the lead anaesthetist and Health NZ, Auckland, for the 2021 incident.
The 73-year-old was getting a mastectomy and a lymph node removed after she was diagnosed with breast cancer.
The report, by deputy Commissioner Carolyn Cooper, noted it was a known complication for breathing tubes to go into the wrong pipe, but it was normally able to be resolved very quickly.
In this case, it was not found until after the woman’s heartbeat and oxygen level dropped during surgery to the point the operating team started doing CPR “with increasing desperation”.
An emergency bell was rung and at one stage there were a many as 20 people in the operating theatre.
The lead anaesthetist, known only as Dr C, said multiple factors combined to “create an extremely confusing crisis”.
Measurements and observations initially appeared to show the tube was in the right place but it became apparent something was wrong.
The junior doctor who inserted the tube said she asked to redo it several times in case it was not in properly.
But Dr C refused because he thought the woman was having a bronchospasm (narrowing of the airways), which she had had in an earlier surgery, the junior doctor told the report.
He worried taking out the tube would mean they might lose the ability to keep her airway open.
Doctors and theatre staff reported differing details, sometimes disagreeing, but Dr C said he took responsibility, as the leader.
There was an “overwhelming expectation of bronchospasm” because of the woman’s past history, he said in the report.
He had dealt with multiple food pipe intubations over past years – and all had been diagnosed and rectified quickly, he said.
The woman was a very complex case because of her body mass index of 44, previous cancers, a nodule in her lung and, most pointedly, serious complications with ventilation in an earlier operation.
Health NZ told the Commission unrecognised oesophageal intubation was a very rare problem, likely occurring in one in a million anaesthetic treatments.
It viewed the complication as a system-based problem, not the failing of an individual.
However, the deputy commissioner criticised Dr C for not responding quickly enough to concerns the tube was in the wrong place, and for not taking a hands-off leadership role as the senior clinician on the case so that he could step back and consider the entire situation.
He also did not follow the crisis checklist, a list on the wall of the theatre with a step-by-step guide to use when something goes seriously wrong, Cooper said. Her report did note the woman’s situation was not one of those covered on the list.
Cooper also criticised Health NZ, Auckland, saying there were systemic problems including a lack of leadership and a lack of teamwork.
Health NZ said changes had been made since then, including educating staff about the case.
Dr C said he had changed his practice and undergone further training on airway emergencies.
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