Glenda Logsdail
6 Sept 2021 · Coroner Sean Cummings · Milton Keynes
The coroner's concerns
1. lack of awareness of capnography campaign
“I was concerned to find that the anaesthetising Consultant [name redacted] was not aware of the Royal College of Anaesthetists campaign video”
2. lack of awareness of capnography campaign
“I became even more concerned when towards the end of the Inquest when I was hearing evidence on the Incident Investigation Report the author, told me he had not been aware of the campaign himself until this incident.”
3. absence of capnography confirmation
“As Mrs [name redacted] condition deteriorated there was no evidence that any confirmatory checks, notably looking for the presence of a capnography trace or expiratory misting, were done to check correct placement of the endo tracheal tube”
4. fixation on anaphylaxis as cause
“As Mrs [name redacted] deteriorated Dr erroneously fixated on a diagnosis of anaphylaxis being responsible for the collapse”
5. hierarchical inhibition of communication
“There was evidence of an inhibitory hierarchical structure which prevented others shouting out”
6. inappropriate task delegation
“The panic and chaos led to an inappropriate delegation of an irrelevant task to a Consultant [name redacted] who attended to assist who eventually was the one to realise the ET tube was misplaced”
Responses
2021-0295-Response-from-Department-of-Health-Social-Care_Published.pdf ↗· Milton Keynes University Hospital
Stated action
“is currently implementing a specialty training recovery project that is seeking to enhance the use of simulation-based training across all postgraduate specialties. One specific theme within this work, is developing professional capabilities that support team-based practice in complex or life- threatening situations.”
2021-0295-Response-from-Milton-Keynes-University-Hospital_Published.pdf ↗· Milton Keynes University Hospital
Stated action
“we have shared resources in relation to 'no trace, wrong place' widely within the organisation, we have implemented the Association of Anaesthetists Quick Reference Handbook in our theatres, and we have ensured (as covered at Inquest) that monitor configuration across theatres is standardised.”
2021-0295-Response-from-Royal-College-of-Anaesthetists.pdf ↗· Anaesthetists