Inquest into the death of Brooke Tiddy

Case Number: 2018/00290847

Date of Findings: 17 November 2025

Magistrate: State Coroner, Magistrate Stuart Devine

Catchwords: CORONIAL LAW – elective bariatric surgery - adequacy of pre-operative assessments – particularly pre-anaesthetic screening - rare condition - Sponastrime Dysplasia - communication between treating doctors - loss of anaesthetic - manner and cause of death

Responses

Recommendations

To St George Private Hospital

1. That St George Private Hospital give consideration to reviewing and, if considered appropriate, amending its present Compromised Airway and Difficult / Awake Intubation Policy, in particular the section titled “COMPROMISED AIRWAY PROCEDURES” concerning the need for a pre-anaesthetic consultation by referring and the need for adherence to, the relevant ANZCA (Australia and New Zealand College of Anaesthetists) guidelines.
2. That St George Private Hospital give consideration to reviewing and, if considered appropriate, amending its present Admission Policy, in particular the statement on page 1 of that policy, namely:
   “Patients with chronic or complex medical conditions should be carefully worked up. Appropriate associated specialist may need to assess patient prior to admission.”
   with a view to making clear on whom the onus falls as to who it is who is to determine that the patient be carefully worked up.
3. That St George Private Hospital give consideration as to how it may educate and inform Doctors with admitting rights or those Doctors who work at the hospital about the Hospital Policies applicable to their area of practice at the hospital.
4. That St George Private Hospital give consideration to reviewing, and if considered appropriate, amending its present Anaesthetic Policy to require the anaesthetic technician to remind the anaesthetist to print the data from the anaesthetic machine where it has not otherwise been printed so as to ensure that it has been included within the patient’s medical records.