The ACT's chief coroner has recommended earlier involvement of anaesthetists in complex medical cases after a woman fighting tongue cancer died following a risky operation to remove some of her teeth at Canberra Hospital.
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Maxine Fulton, 68, died nine days after doctors attempted a second surgery to extract four teeth before she began radiation therapy for a large and growing tumour on her tongue in late 2013.
The hospital's treatment of Mrs Fulton was scrutinised in the ACT Coroner's Court earlier this year as an inquest explored whether systemic failings were involved in her death.
The surgery, which was generally considered straightforward, had been complicated in Mrs Fulton's case due to the size and location of the tumour, her complex medical history and because she was frail and anxious at the time.
There was a danger that medical teams would not be able to keep her airway clear during the procedure, particularly with the added risk of having her under anaesthetic or sedation.
Concerns were raised that Mrs Fulton had not been adequately informed of the risks, referred to an anaesthetic clinic, or signed a separate anaesthetic consent form in the lead up to the operation.
There was also no anaesthetist at an early multidisciplinary team meeting to discuss her options for medical treatment soon after her diagnosis.
The inquest heard the hospital's Christmas shutdown for elective surgery lists was looming and Mrs Fulton had been keen to start radiation therapy as soon as possible.
She was put under general anaesthetic when doctors first attempted the surgery on December 10.
That procedure had to be abandoned after several failed attempts to secure an open airway through intubation failed and it was rescheduled for the next day.
The decision to go ahead with the second surgery was criticised during the inquest by Professor Alastair Goss, an eminent surgeon, who said it was a "high-risk call with a high chance" of what would eventuate.
He said the failed intubation would have irritated the tumour and probably caused swelling, bleeding and more chance of obstruction.
Mrs Fulton had grown distressed before she was taken into surgery early on December 11 because she had expected the surgery would be performed later that afternoon.
Her husband, John Fulton, had recalled her last words to him were: "I'm frightened."
She was put under local anaesthetic and sedated for the operation but as doctors worked on the fourth tooth, her breathing became obstructed and she went into cardiac arrest.
Mrs Fulton was resuscitated but died in hospital on December 20.
Ms Walker expressed her condolences to Mr Fulton for his loss as she handed down her findings in court on Friday.
While she identified a need for better communication between surgeons and anaesthetists about potential risks linked to Mrs Fulton's treatment, Ms Walker said there was no criticism levelled at the technical skills of the medical staff.
She identified a need for anaesthetic specialists to be involved in complicated cases at an earlier stage so that appropriate procedures and potential risks around anaesthetic use could be properly assessed.
She also recommended a separate anaesthetic consent form be made available to patients in complicated matters to encourage medical staff to consider the implications of anaesthetic problems in relation to other treatment.
"It would also allow patients to give proper regard to risks associated with anaesthesia," she said.
Ms Walker said it was unfortunate records that had monitored the anaesthetic process during Mrs Fulton's surgery had gone missing, saying reliance on paper records was "very unsatisfactory".
She said an appropriate storage system for such records would allow practitioners to later assess situations to properly understand what happened, with a view to reducing further risk.
