Woman dies after ‘catastrophic chain of errors’ during and after abscess draining surgery
The tragedy began with incomplete reversal of the neuromuscular block used during surgery, the NT Coroners Court heard.
A “catastrophic chain of errors” during and after an Indigenous woman’s abscess drainage surgery ultimately led to her death from hypoxia, a coroner has found.
NT Coroner Judge Elisabeth Armitage says the patient, called Ms Guyula in the inquest findings, endured a “chain of tragedy”, including incomplete neuromuscular block reversal after surgery on a 12cm x 8cm boil.
When Ms Guyula deteriorated in the post-anaesthetic care unit, the anaesthetic registrar then placed an intubation tube into her oesophagus, Judge Armitage found.
The error went uncorrected for five minutes.
