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'Doctors did something...somebody died' - coroner
By
Dayle Crutchlow
A
20-YEAR-OLD Zimbabwean man admitted to Walsgrave Hospital in Coventry,
England, after a minor car crash died after doctors blocked his airways
as they treated him, an inquest has heard.
Michael Madondo crashed his car into a parked lorry in Gielgud Way, at Cross Point Business Park in Walsgrave, on December 8 last year, but walked away with facial injuries.
A local newspaper, the Evening Telegraph, later reported how his devastated relatives could not understand how Michael could have died, because he was fit and healthy and had been able to walk from the ambulance into the hospital and give his personal details to staff.
Michael, who came from Zimbabwe in 2003 and was a security guard in Walsgrave, lived in Fisher Road, Foleshill, with his aunt and uncle.
As she waited in hospital, his aunt, Ntombiyelanga Mgutshini, had been told by a nurse that his injuries were not life-threatening.
But the inquest was told how her nephew died after doctors had needed to give him oxygen but failed three times to create a sufficient airway.
Finally they decided to give a mini-tracheotomy, where they make a direct incision into the windpipe in the neck.
But Dr Anne Anthony, clinical director of emergency medicine at Walsgrave, failed to perform the procedure successfully.
She told the inquest: "I have never had to perform a mini-tracheotomy in my medical practice but it's a skill I actually teach in one of the many courses I instruct at."
Doctors then decided to perform a surgical tracheotomy and it was as surgeons prepared to carry out this procedure that Mr Madondo died.
Pathologists gave the cause of death as "haemorrhage into the lungs following facial injury and haemorrhage into the right plural cavity following the insertion of a tracheotomy".
The inquest, at Coventry Magistrates' Court, also heard that on Mr Madondo's arrival at the hospital at 10.30am neither of the two A and E consultants was contactable.
Dr Anthony eventually had to be fetched from her office to treat him.
Passing a narrative verdict, coroner David Sarginson said: "Mr Madondo died after being admitted to hospital in an alert and stable state, with severe facial injuries, and had his airways blocked in the course of medical procedure."
The coroner was critical of the hospital in his summingup. He said: "Neither of the A and E consultants could be contacted, despite a three or four-minute warning from the ambulance of their impending arrival.
"This was an unsatisfactory state of affairs at 10.30am on a Thursday morning.
"Dr Anthony said she had never performed a mini-tracheotomy but she could teach it.
"In the circumstances I thought it astonishing that she should say what she said.
"It was attempted to carry out a surgical tracheotomy but at that stage cardiac output was lost and he was certified dead at 11.38am, just about one hour after his arrival in hospital."
Mr Sarginson added that it was accepted that the fundamental principle of medical treatment was ABC - airways, breathing and circulation.
He said: "When Mr Madondo arrived at hospital they were all working. The staff managed to compromise all three.
"I will not endorse what the doctors did. Neither will I criticise what the doctors did.
"The doctors
did something and the consequences are that somebody died." - ic
Coventry
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