Colin Michael SWAIN · Prevention of Future Deaths report

On 08 June 2021 I commenced an investigation into the death of Colin Michael SWAIN aged 42. The investigation concluded at the end of the inquest on 04 March 2022. The conclusion of the inquest was that Mr Swain died from Hypoxic brain injury due to aspiration of the gastric contents following alcoholic intoxication. It was not possible on the balance of probabilities to determine the point at which Mr Swain’s brain was starved of oxygen such that he would stop breathing, and whether turning him from his side to his back for CPR commenced caused or contributed to his death.

On 22 May 2021 Colin Swain, who had a history of alcohol excess, but did not drink in the presence of his family, was found collapsed in his front garden after going outside for a cigarette and a drink. The toxicology results indicated a level of alcohol associated with a coma. During the emergency call to the ambulance service the call handler was informed that he had been drunk, had fallen hitting his head and was unconscious. His breathing was assessed by the call handler and found to be agonal. The advice was to commence CPR for which he needed to be on his back. He was at that time on his side with his head down. Mr Swain vomited as he was turned, and advice was given to clear his mouth. Immediately upon turning him to his back Mr Swain stopped breathing.

Bystander CPR followed until the ambulance service attended and achieved ROSC to transfer him to hospital. On admission the CT scan indicated hypoxia and he was presumed to have consumed enough alcohol to produce an obtunded state of consciousness with alcohol as the precipitant cause of death. Airway protected reflexes could fail in these circumstances, and in the absence of medical help, laryngospasm could be lethal. The clinical evidence was that he had aspirated his stomach contents which would itself have caused hypoxia worsened by a degree of laryngospasm closing the airway completely. The anoxic insult which can occur within 4 minutes lasted long enough to stop his heart.

The paramedic attending the scene gave evidence that in agonal breathing the only course available to a bystander was to commence CPR pending arrival of an ambulance. For that to happen a patient had to be laid on their back.

(1) When a patient has been known to have been drinking alcohol, whether there is an algorithm in the MPDS detector which takes this into consideration.

(2) If the MPDS does provide support for alcohol intoxication, whether this includes support in how to clear the mouth and nose to good effect. If it does not, whether this something which could be included in the Tool.

(3) Whether turning an unconscious patient onto their back after vomiting is good practice, in the absence of clinician support