A Canberra doctor has told a coronial inquiry of the chaotic communication between emergency medical staff treating a woman who died less than a fortnight later.
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Suki Thurairajah had been admitted to the Canberra Hospital for haemodialysis to remove waste from her blood caused by kidney failure in July 2011, but complications with breathing led to the placement of a tracheal tube.
An interim finding by the coroner found the tube had been incorrectly put down the 55-year-old’s oesophagus, pushing air into her stomach instead of down her windpipe and into her lungs.
She spent 10 days in a coma before being declared dead.
Claire-Mary Thomsett broke down in tears while giving evidence into the incident, which left Mrs Thurairajah without oxygen for as long as 10 minutes.
The anaesthetic registrar told the ACT Coroner’s Court she had never performed an emergency placement of the tracheal tube before July 29, 2011, when she was called to the patient’s room via an emergency page.
Two doctors had already been in the room, but Dr Thomsett said she had been forced to break with her normal practise and do multiple parts of the procedure on her own after requests for assistance weren’t responded to.
This involved putting down a light, which is generally used to ensure the tube was inserted correctly into the throat.
She said she had relied on other doctors to confirm signs of the tube being placed correctly, but described the communication within the team as chaotic.
“I thought it was chaotic and not necessarily very clear,” she said.
“… In my personal opinion, better communication would’ve probably prevented some of these issues.”
Dr Thomsett also told the court the training available for such emergency situations was inadequate and believed more senior people than herself, a first-year anaesthetic registrar at the time, should respond to the calls.
“I think it should be more senior people that go,” she said.
“There’s not much point in sending someone with seven, eight months of training under their belt.”
Dr Ramsy D’Souza also gave evidence at the hearing.
Dr D’Souza said he was not actively involved in the intubation, but was one of the first medical staffers to arrive.
“It was chaotic,” he said.
“… At that stage, there was chaos and there was no clear team direction.”
The hearing in the ACT Coroner’s Court continues on Wednesday.
