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A 57-year-old woman presented to her PCP for pre-operative clearance for a bilateral salpingo-oophorectomy.

She had HTN, and denied chest pain, SOB, palpitations, dizziness, or swelling.

Testing included CBC, CXR, EKG, CMP all within normal limits.

At the hospital her care was by an MD and CRNA in a care team model, both employed by a national anesthesia practice.

Following the surgery, she arrived to PACU with a nasal airway in place, still sedated.

Oxygen levels were in the 80s.

Still hypoxic and sedated, Narcan was given without effect.

Bipap therapy was started.

Her O2 sat continued to decline.

She was intubated and 20 mins later desaturated to the 60s and became pulseless.

A code was run for 45 minutes before she was pronounced dead.

Her daughter sued the PCP, PCP practice, anesthesiologist, CRNA, anesthesia practice, and the hospital.