Joseph Parker
19 Jul 2024 · Coroner M.E. Voisin · Avon
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. unconfirmed tracheal tube placement
“capnography is the only reliable test, the gold standard, to confirm that a tracheal tube is in the right place, that no other test should override it”
2. lack of dissemination of PUMA guidelines
“The PUMA guidance deserves the widest possible endorsement and dissemination which has not happened yet”
3. oesophageal intubation classified as Never Event
“Unrecognised oesophageal intubation was a "Never Event" by NHS England but is no longer”
4. repeated reports without corrective action
“There have already been a number of Prevention of Futures Deaths Reports written by Coroner's in relation to this concern but to date, I am told there have been no changes”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“During the course of evidence | heard that an (admitted)”
This report
“(1) I have been told that capnography is the only reliable test, the gold standard, to confirm that a tracheal tube is in the right place, that no other test should override it.”
Responses
2024-0389-Response-from-Association-of-Anaesthetists-RCOA-and-Faculty-of-Intensive-Care-Medicine-Joint-Respons.pdf ↗· Faculty of Intensive Care Medicine
2024-0389-Response-from-NHS-England.pdf ↗· NHS England
2024-0389-Response-from-Royal-College-of-Emergency-Medicine.pdf ↗· Royal College of Emergency Medicine
Stated action
“we will continue to work closely with the Faculty of Intensive Care Medicine and seek to improve upon our existing guidance to highlight the importance of waveform capnography in the early recognition of oesophageal intubation.”