This is another coroner’s inquest that will be of interest to readers of this blog – Inquest into the death of John Davis, Queensland Coroners Court, 17 April 2019.

Mr Davis was a 50 year old man with ‘acquired brain injury from birth resulting in intellectual impairment and epilepsy, severe obstructive sleep apnoea, gastro-oesophageal reflux disease and osteoporosis’ ([1]).  He was living in supported care.  The circumstances of Mr Davis’ death were described at [3]-[8]:

At approximately 11:00am on 8 April 2018, Mr Davis and the three other residents at the facility were given lunch by their daily carer Mr Joseph Oderinde … Mr Davis was heard to collapse to the floor. Mr Oderinde found Mr Davis unresponsive. Mr Oderinde called 000 and monitored Mr Davis’ response with the assistance of the Emergency Medical Dispatcher (EMD). When it became apparent Mr Davis was not breathing he was instructed to perform cardiopulmonary resuscitation, which he did until the first paramedics arrived.

A total of three Queensland Ambulance Service (QAS) crews were eventually dispatched to the residence as Mr Davis deteriorated. When paramedics first arrived they found Mr Davis with a Glasgow Coma Scale (GCS) of 3 and in pulseless electrical activity (PEA). Mr Davis had no cardiac output and was noted to be difficult to ventilate. After initial difficulty with a faulty laryngoscope [where the light did not work so the paramedics could not ‘see below the oral cavity’ ([100])] and the attendance of a Critical Care Paramedic, a large piece of meat was cleared from the airway using a different laryngoscope. Mr Davis was subsequently easier to ventilate and returned to spontaneous cardiac activity.

Mr Davis could not be intubated at the scene and was successfully ventilated using a laryngeal mask airway. Apart from the difficulties in clearing the airway due to instrumental issues, there were some issues relating to proper documentation of the event on the Electronic Ambulance Report Form (eARF)…

Mr Davis was transferred to the SCUH and was noted to be spontaneously breathing and easy to ventilate with the laryngeal mask airway. He remained at a GCS 3 and was intubated.

A CT scan revealed changes consistent with significant brain injury due to the period without blood and oxygen supply, known as hypoxic-ischaemic encephalopathy. The CT scan also revealed that changes related to his previous brain injury, which was reported as being stable in comparison with scans taken in January 2014 (over 4 years earlier).

Mr Davis made no significant recovery and died at 00:50am on 10 April 2018.

The Coroner investigated many aspects of Mr Davis’ care but relevant to this blog is the discussion around CPR and the QAS response.  A review by QAS found (at [101]-[102]):

  • Officers Lahood and Nightingale failed to adequately identify and manage a patient with a foreign body airway obstruction.
  • The primary patient care eARF was of significantly poor standard with major errors and admissions.
  • Officers Lahood and Nightingale failed to self-report this case as a clinical incident.

Additionally, significant and vital equipment failure occurred during the incident (probable flat laryngoscope batteries), with no documented pre-shift vehicle and equipment check for that day.

In reviewing the evidence it was clear that there were communication difficulties between Mr Oderinde and the EMD.  There was conflicting reports back to the EMD as to Mr Davis condition.  At times MR Oderinde reported that Mr Davis was breathing when the sounds on the recording of the triple zero call suggested that there was no effective breathing.  With respect to Mr Oderinde’s response the coroner said (at [150]-[154]; emphasis added):

It is apparent Multicap [the operator of Mr Davis’ accommodation] ensures all its DSWs [Disability Support Workers] have up to date First Aid and CPR training…

DSWs do not provide clinical care and could not be expected to in the circumstances. The appropriate policy in place was for DSWs to follow their training and call emergency services.

In this case it is evident Mr Oderinde cleared the area to make it safe for CPR, checked the airway and rang 000. Mr Oderinde did not observe any obstruction and it is fair to say neither did Officer Lahood.

I find on balance that Mr Oderinde was wrong about the time he called 000 and it was much closer to 12:07pm than 11:52am. It may have been whatever time piece he used that showed this timing was incorrect. I accept there may have been a few minutes pass while he cleared some space, placed him in an appropriate recovery position and checked his airway, and there may have been some time before the 000 call went through to QAS but I do not believe Mr Oderinde did nothing for a number of minutes.

What happened from there was not optimal in that there was a clear difficultyin the transfer of accurate information between Mr Oderinde and the 000 EMD. What was evident to me, and a reason why Dr Rashford was asked to review the call, is that it was possible what I was hearing was perhaps agonal breathing some minutes before CPR commenced. Dr Rashford is of the opinion that was the case. I am not critical of Mr Oderinde in being unable to recognise this for what it was as it is clearly out of the scope of practice of DSWs to make such clinical judgments.

With respect to the QAS response the coroner said (at [155]-[161]):

The issue of the call received by the QAS EMD was very robustly analysed by Dr Rashford [Medical Director for QAS] where he concluded that on balance the call was not handled optimally.

Dr Rashford stated that from listening to the call the EMD found the case very difficult due to the conflicting information being presented. Having listened to it on a number of occasions I can only agree.

Dr Rashford found there were understandable human factors at play that resulted in a delay in recognising the choking episode complicated by cardiac arrest. Despite that, there was no delay to paramedics arriving on the scene.

Given Dr Rashford’s evidence about the significant education in this area that has been undertaken and is continuing to be developed, I do not see the need to further comment or consider further recommendations in this regard.

QAS also investigated the actions of the various paramedics at the resuscitation and subsequent to it. The investigation considered two paramedics failed to adequately identify and manage a patient with a foreign body airway obstruction. This finding is mitigated to some extent by the relative rarity of the paramedics coming across foreign body airway obstruction conditions and infrequent experience of real-time direct visualisation laryngoscopy by ACPs.

The two paramedics concerned have received further training in airway management and in the use of laryngoscopes and have otherwise been performance managed.

The evidence supports a finding that by the time paramedics arrived Mr Davis had been in cardiac arrest for some time and would have already suffered a degree of hypoxia from which it was unlikely he could recover. That being said, it evident the earlier CPR commenced (likely to have been ineffective until the obstruction was removed) and the earlier the removal of the food bolus obstruction occurred, then the better the chance of a more favourable outcome eventuating.

As with the inquiry into the State Mine Fire (see Two coroners inquests that may be of interest (May 21, 2019) the coroner was assisted by an agency inquiry, in this case the review by QAS, and their report on what training they had introduced generally, and specifically with respect to those involved in the case.  In light of the steps QAS had taken to ensure that their call takers and paramedics were informed and trained, the coroner said (at [162]) that he did:

… not consider any recommendations need to be made to QAS in respect to its findings on its investigation as there is clearly ongoing improvement processes as part of its organisational ethos and it is best placed to drive those forward

The coroner did recommend that other disability service providers consider adopting a checklist developed by Multicap to assist service providers ‘to identify future residents who may have swallowing/choking risks’ (see [164]-[165]).

Again, however, no adverse comments directed to Mr Oderinde, the paramedics or QAS.  A review of a tragic case where provided care was sub-optimal but with recognition of the factors that contributed to that and recognition of steps already taken by Multicap and QAS to improve future performance.  The coroner reviews past cases to make forward looking recommendations. Although coroners can make adverse findings and recommend criminal prosecutions, that is rare and doesn’t arise just because someone died and sub-optimal responses can be identified.


I am reminded of an earlier post – Confined space rescue – Queensland (May 13, 2019) where the question I was asked ended with ‘… would a company’s risk assessment stand up in coroners court when it follows processes outside/contradicting of industry best practice?’  One can’t be too specific, as I say coroners can make adverse findings (see 2003 Canberra bushfires, the coroner and litigation (June 26, 2009)) and can refer people to the DPP for possible criminal prosecution that is not the norm.  What one might expect if there appears to be a poor risk assessment is that the coroner would ask the company ‘and what have you done to fix the problem?’ and perhaps make recommendations for others to avoid similar, tragic circumstances (see also First aid and paramedic care – and coroners are not out to get you (December 1, 2018)).