During the procedure, performed in the emergency department, the tube was incorrectly placed in the man’s oesophagus instead of his trachea.
Dr Caldwell identified several factors that contributed to the man’s death, including a lack of standardised equipment, superior equipment not being made available and staff members believing that certain equipment was not functioning properly.
“I am critical that Te Whatu Ora did not ensure that there was suitable equipment for difficult airway management available in the ED, and that there was a lack of standardised equipment across the hospital,” she said.
“I am also critical that the staff were not made aware of the equipment that was available, and that the staff were not reassured that the equipment was functional and being maintained adequately. In my view this contributed to the delay in diagnosing the oesophageal intubation.”
However, in response to his whanau questioning consent not being obtained prior to the procedure, Dr Caldwell said that “given the emergency situation following [the man’s] arrival in the ED, the decision to intubate was necessary, and in these circumstances it is reasonable that [his] consent could not be sought at the time.”
Te Whatu Ora Te Matau a Māui has made several changes since the death, including purchasing new equipment and forming an airway committee comprising anaesthetics, ICU, ED and ear, nose and throat departments. The committee has reviewed and standardised airway equipment between ED, ICU and the operating theatre.
It has also established an equipment testing and checking regime, developed difficult intubation, and airways checklists, and reviewed the ED red alert response. Interdepartmental simulation training has also been put in place.
Dr Caldwell also recommended Te Whatu Ora provide a written apology to the man’s whānau and put in place regular training for all current staff in ED and ICU on the standard practice in emergency airway management.