A coronial inquest has found the death of a 19-month-old girl at Port Macquarie Base hospital two years ago could've been prevented.
In February of 2019, a Sydney family was holidaying in Port Macquarie when their daughter was accidentally bitten on the finger by a black cockatoo after placing her hand inside a bird enclosure at a local wildlife park.
She was taken to Port Macquarie Base Hospital for treatment, where medical staff decided surgery was appropriate.
Doctors decided to perform the surgery under general anaesthetic with an endotracheal tube (ETT) — a flexible plastic tube that is placed into the trachea (windpipe) to maintain an open airway.
Deputy State Coroner Magistrate Derek Lee said it was found the ETT was incorrectly placed into the oesophagus.
"The oesophageal intubation [incorrectly placed ETT] resulted in sudden deterioration of the girl's condition," he said.
"Her heart rate and oxygen saturations decreased to precariously low levels and she went into cardiac arrest.
A preventable death
Coroner Lee said there were a number of signs indicating the ETT had been place incorrectly, but staff failed to recognise them.
"A constellation of signs ... ought to have alerted the members of the anaesthetic team to both the First ETT and Second ETT being in the oesophagus, rather than the trachea," the coroner said.
However, Coroner Lee acknowledged the medical team could have missed their mistake due to the challenging environment they were in, with a patient that was clinically deteriorating.
He said the team thought of multiple other causes for the girl's deterioration.
"The anaesthetic team became anchored in their thinking and fixated upon other reversible causes of her deterioration," he said.
Coroner Lee also found the Wildlife Park bore no blame for the injury.
"The available evidence did not identify any issues associated with warning signage or fencing relating to the bird enclosure at the park that directly contributed to the accident," he said.
Health district sorry
Mid North Coast Local Health District Chief Executive Stewart Dowrick said the organisation offers its sincere condolences to the victim's family and apologises for the tragic incident which occurred two years ago.
In a statement, Mr Dowrick said since the incident, appropriate measures have been put in place at Port Macquarie Base Hospital to help prevent another tragedy of this kind.
Coroner Lee said the hospital has also established a support network with a tertiary paediatric facility, to train staff and develop appropriate clinical skills.
"Such a network provides support for simulation training ... some of which seeks to address the challenges faced by clinicians on 4 February, 2019, and provide for improved outcomes.
The family wanted to keep their loss private and remain anonymous.
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