Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0389, written 19 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jul 2024 |
|---|---|
| Reference | 2024-0389 |
| Deceased | Joseph Parker |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
M. E. Voisin Her Majesty’s Senior Coroner Area of Avon 13 June 2024 REF: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: • Royal College of Anaesthetists (RCOA) • Faculty of Intensive Care Medicine (FICM) • Royal College of Emergency Medicine (RCEM) • NHS England 1 CORONER I am M. E. Voisin HM Senior Coroner for Avon 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 21/4/22 an investigation into the death of Joseph Lawrence Parker was commenced. The investigation concluded at the end of the inquest on 4/5/24. The conclusion of the inquest was a narrative, recorded as follows: “The deceased Joseph Lawrence PARKER died on 16 April 2022 at Southmead Hospital. On 17th February 2022 he had taken an overdose of medication which caused his collapse. He was taken to hospital and required intubation. During the procedure the tube was accidentally positioned in the oesophagus, this accidental misplacement should have been identified due to the volume of vomit coming from the tube and the lack of a recognisable capnograph at that time. Once accidental osophageal intubation was recognised he was correctly intubated. The incorrect placement caused him to suffer a cardiac arrest, which led to hypoxic encephalopathy and his death.“ 4 CIRCUMSTANCES OF THE DEATH On 17th February 2022 Joe’s parents couldn't wake him, so called 999. The first paramedic was on scene at 07.16hrs. Joe was unconscious, but not in cardiac arrest, his oxygen levels were low at 12, he could see evidence of vomit, an oropharyngeal airway was put in and his oxygen levels went up to 48%. Joe vomited and they had to suction his airway. Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL Joe was taken to Southmead Hospital. During the journey Joe confirmed he had taken and an unidentified tablet. , The Consultant in Emergency Medicine, , confirmed that after Joe arrived, and following a rapid assessment of him, colleagues from the Intensive care unit were called as Joe needed to be intubated. , attended from the intensive care unit to carry out the intubation, he called his colleague to assist and to supervise the intubation. Joe was pre-oxgenated. Intubation began at around 9.37am. Video laryngoscope was used to view the chords, both could be viewed. saw the bougie enter the windpipe, over the bougie, as he did this it became stuck on cartilage which meant that he had to rotate the tube, the bougie was then taken out, and the cuff was inflated. The tube was not tied in and he accepted that it should have been done immediately. then inserted the bougie into the airway, both doctors said that they then inserted the breathing tube, by railroading it said that the chords and It appears from the evidence that both to check for an end tidal trace. tube placement, he added that he didn't think he would ever have confirmed without seeing at least 3; checked the capnograph at this point said he didn’t know how many, but that he had confirmed and said we saw 3 breaths on the monitor. also referenced the other indicators which were: chest wall movement, breath sounds in the chest, fogging in the tube. He accepted that on their own they are unreliable but that they supported the view that the tube was in the right place. said that she would have been looking at the monitor as well and she thinks she saw a few end tidal carbon dioxide traces 2 or 3. What is clear from the evidence is that at the time there was no standard guidance on what the requirement was in relation to the capnography. At the time the campaign was no trace wrong place. What happened next and the exact sequence of events varied slightly between the witnesses. There was aspirate/vomit which resulted in suctioning of the airway which I am told was not unexpected, as they were aware that Joe had previously vomited. The aspirate then quickly became larger volumes of vomit. Both doctors accepted that with hindsight the amount of vomit was too much to come from the lungs. During this time Joe’s oxygen levels were dropping and he was heading to cardiac arrest so he called for , Consultant in Anaesthesia and Intensive Care Medicine. back-up from Joe went into cardiac arrest, at around 9.41am, chest compressions were started, advanced life support was given. arrived, he noted no trace on the capnograph and asked if the tube was in the right When place, he said, because of the uncertainty, he looked with the laryngoscope and saw that it was in the osopahagus, he took it out and put in a new tube Return of spontaneous circulation was achieved after Joe had been correctly intubated at around 9.48 - 9.49am Joe was taken to the intensive care unit but unfortunately did not recover due to a significant brain injury. , Specialist in Intensive Care Medicine and Anesthetist provided his expert opinion, of note he said: • The initial cause of Joe’s neurological decline was the opiate overdose, with initial early recovery due to the actions of the ambulance staff. • He continued to have impaired respiratory function but his respiratory rate was normal with low oxygen saturations. • Once at the emergency department the decision was made to intubate Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL That the tube was found to be in the oesophagus, this is a recognized complication. It was after accidental oesophageal intubation that Joe went into cardiac arrest. That it was during the cardiac arrest that the hypoxia caused the brain injury. That the standard at the time was to see a recognisable waveform trace on the capnograph. That if the tube is in the oesophagus you can still get some trace • • • • • • He agreed that they needed to pass suction to deal with the aspirate which was expected, but that the volume of vomit was not questioned, he said that it is a much smaller volume of vomit that would be in the airways, That the time when the clinicians should have focused most attention on the end tidal trace is after intubation and then if not progressing as expected to re-assess the end tidal trace. It is unlikely that there was a recognizable capnograph trace in this case. So recognition of the accidental oesophageal intubation should have occurred relatively early, but in this case did not. That the volume of vomit should also have triggered a suspicion of accidental oesophageal intubation. That they should have re-intubated, which would have meant that the period of hypoxia would have been transient and would not have resulted in Joe’s death. • • • 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – Both report should be written in this case. and who were involved with this case have written to me supporting that a PFD (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. (2) That the more recent PUMA (Project for Universal Management of Airways) guidelines states, the detection of sustained exhaled carbon dioxide using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. The PUMA guidance deserves the widest possible endorsement and dissemination which has not happened yet. (3) Unrecognised oesophageal intubation was a “Never Event” by NHS England but is no longer. (4) 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. Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th September 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the chief coroner and to the following interested persons: • Family of the deceased • North Bristol NHS Trust • • South Western Ambulances Service Trust I have also sent a copy to . I am also under a duty to send the chief coroner a copy of your response. The chief coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the chief coroner. 9 19.7.24 Signature M. E. Voisin HM Senior Coroner for Avon Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
11th September 2024 Dear Ms Voisin, Re: Regulation 28: Report to Prevent Future Deaths in the matter of Mr Joseph Parker Thank you for sending us a copy of your Regulation 28 Report regarding the sad death of Mr Joseph Parker. We have jointly reviewed the information available to us in the report via our Safe Anaesthesia Liaison Group (SALG). SALG is a collaborative project between the Association of Anaesthetists, NHS England’s Patient Safety team and the Royal College of Anaesthetists. One of its core objectives is to analyse anaesthesia- related serious incidents and to share the learning with the specialty across the UK. We have also reviewed the information available with the Faculty of Intensive Care Medicine (FICM) in order to prepare this joint response. As your report highlights, this is sadly not the first death as a result of unrecognised oesophageal intubation that has been referred to our organisations by your fellow coroners. It remains a great concern to our organisations that such incidents continue to take place, despite the work previously carried out by the specialty to try to ensure that oesophageal intubations are swiftly recognised and corrected. Your report highlights that “capnography is the only reliable test, the gold standard, to confirm that a tracheal tube is in the right place and that no other test should override it.” We agree entirely and this is made clear in the Association of Anaesthetist’s “Standards of monitoring during anaesthesia and recovery”1. The message has been emphasised in our previous communications to members on the topic2 and will continue to be at the heart of future communications. Our previous campaigns, in 2018 and again in 2021/22, have emphasised the “no trace = wrong place” message3. The Project for Universal Management of Airways (PUMA) consensus guidelines for the prevention of unrecognised oesophageal intubation’s4, emphasise “sustained exhaled carbon dioxide” as the test to exclude potential oesophageal intubation. This reflects the fact that in some cases of oesophageal intubation the capnograph trace has not been flat, but instead attenuated and abnormal. Our organisations are all supportive of the PUMA guidelines and plan to disseminate the key messages to our members through our safety communications and events. SALG publishes regular Patient Safety Updates, which are distributed to all members of the Association of Anaesthetists and Royal College of Anaesthetists. FICM publishes regular Safety Bulletins, which are distributed to all their members. Guidelines are in place, but in order for them to be successful in preventing unrecognised oesophageal intubation, we also recognise the importance of human-factors based strategies to enable their use, as outlined in the Association of Anaesthetists’ guidance “Implementing human factors in anaesthesia”5. In particular, multidisciplinary team training in the management of emergency situations is key in preventing unrecognised oesophageal intubation. As well as helping to ensure that individuals are familiar with the relevant algorithms, by rehearsing emergency drills, teams practise non-technical skills and learn how to function well as a whole within a flattened hierarchy, which contribute to safe and efficient task performance.5 Regular, multidisciplinary team training is one of the standards for the RCoA’s Anaesthesia Clinical Services Accreditation (ACSA) scheme. However, in practice, it is a standard that many departments find difficult to meet to an adequate level due to the pressure on theatre time. To support this, we have created and promoted resources that can be delivered regularly within the normal working day.2,6 The RCoA’s Quality Improvement Network is currently undertaking a project to look at the implementation of airway-related recommendations across the country, including those related to unrecognised oesophageal intubation. We will use the information gained from this project to focus our activity to support departments of anaesthesia to make improvements. Your report mentioned that unrecognised oesophageal intubation was a suspended never event. We are aware that the never events framework is under review by NHS England. In our consultation response, we were clear that, whatever changes are made to the framework, we believe that unrecognised oesophageal intubation should be a nationally reportable incident, so that lessons can be learned from every tragic event to prevent its occurrence in the future. We would be happy to respond to any questions that you might have. Yours Sincerely President, Royal College of Anaesthetists President Association of Anaesthetists Dean Faculty of Intensive Care Medicine References 1. Association of Anaesthetists, Recommendations for standards of monitoring during anaesthesia and recovery, 2021, https://anaesthetists.org/Home/Resources-publications/Guidelines/Recommendations- for-standards-of-monitoring-during-anaesthesia-and-recovery-2021 2. RCoA, Patient safety: unrecognised oesophageal intubation, https://www.rcoa.ac.uk/safety-standards- quality/patient-safety/prevention-future-deaths 3. RCoA, No trace, wrong place https://www.rcoa.ac.uk/safety-standards-quality/guidance- resources/capnography-no-trace-wrong-place 4. Chrimes, N. et al, (2022), Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies*. Anaesthesia, 77: 1395-1415. https://doi.org/10.1111/anae.15817 5. Association of Anaesthetists, Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals, 2023, https://anaesthetists.org/Home/Resources- publications/Guidelines/Implementing-human-factors-in-anaesthesia-guidance-for-clinicians- departments-and-hospitals 6. RCoA, Flash Card Team training, https://www.rcoa.ac.uk/safety-standards-quality/patient-safety/flash- card-team-training
Ms Maria Voisin
Senior Coroner
Avon Coroner’s Office
37 Old Weston Road
Bristol
BS48 1UL
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
18 September 2024
Re: Regulation 28 Report to Prevent Future Deaths – Joseph Lawrence Parker
who died on 16 April 2022.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 19 July
2024 concerning the death of Joseph Lawrence Parker on 16 April 2022. In advance
of responding to the specific concerns raised in your Report, I would like to express
my deep condolences to Joseph’s family and loved ones. NHS England are keen to
assure the family and the Coroner that the concerns raised about Joseph’s care have
been listened to and reflected upon.
Your Report raises concerns that the Project for Universal Management of Airways
(PUMA) guidelines for preventing unrecognised oesophageal intubation (including the
use of capnography to confirm the correct placement of a tracheal tube) have not been
widely endorsed or disseminated, and that there have been a number of Prevention
of Future Death Reports written by Coroners in relation to concerns around this issue.
My response focuses on those areas of concern that fall under the remit of NHS
England’s national policy or programmes. NHS England notes that you have also sent
your Report to the Royal College of Anaesthetists (RCoA), Faculty of Intensive Care
Medicine (FICM), and the Royal College of Emergency Medicine (RCEM), who are
better placed to respond to your matters of concern. NHS England will carefully
consider their responses to the Coroner in due course.
We note that the RCoA does have a webpage dedicated to Patient safety:
unrecognised oesophageal intubation which endorses the PUMA guidelines and
highlights the previous Prevention of Future Death Reports. The page links to
resources for the ‘No Trace = Wrong Place’ campaign launched by the RCoA and the
Difficult Airway Society (DAS), which was intended to highlight the correct use of
capnography to prevent undetected oesophageal intubation. This is aimed at all
clinicians involved in airway management.
Your Report also raised the concern that unrecognised oesophageal intubation is no
longer categorised as a “Never Event” by NHS England.
The use of capnography for intubation was included on the Never Events list in 2018.
NHS England’s national Patient Safety Team quickly received feedback that there
were differing views on the type of capnography that should be used, depending on
the age of the patient, and national guidance was required on how capnography
should be interpreted, so the Never Event was suspended until this guidance became
available. The Association of Anaesthetists of Great Britain and Ireland (AAGBI)
developed recommendations for standards of monitoring during anaesthesia and
recovery in 2021 and a consensus guideline in 2022 ‘Preventing unrecognised
oesophageal intubation: a consensus guideline from the Project for Universal
Management of Airways and international airway societies’, both of which make clear
that ‘waveform capnography is the mainstay for excluding oesophageal placements of
an intended tracheal tube’.
The mitigations used to avoid oesophageal intubation, primarily the use of
capnography, which is included in the 2021 AAGBI recommendations referenced
above, does not meet the definition of a Never Event. As part of NHS England’s current
work to review the Never Events Framework and list of Never Events, we will be
clarifying the future direction for the Never Events Framework. Since the completion
of a widespread consultation in May 2024, a decision will be made on next steps which
will determine if the current definition of a Never Event should change and whether
this has implications for including oesophageal intubation on any future list. Further
information on the consultation can be found here and NHS England can update the
Coroner in due course if this would assist.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of
Joseph, are shared across the NHS at both a national and regional level and helps us
to pay close attention to any emerging trends that may require further review and
action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
Ms M E Voisin Her Majesty’s Senior Coroner The Coroner’s Court Old Weston Road Flax Bourton BS48 1UL 13th September 2024 Dear Ms Voisin, Further to your prevention of Future Deaths Notice following the conclusion of your inquest (4th May 2024) into the death of Joseph Lawrence Parker who died on 16th April 2022, we would like to extend our sympathy and condolences to the family and friends of Mr. Parker. We note Mr Parker sustained a cardiac arrest after being intubated by the intensive care team whilst in the emergency department. Initially the oesophagus was intubated and then subsequently (approximately 7 minutes later) this was rectified by tracheal intubation which resulted in return of spontaneous circulation. Unfortunately, Mr Parker did not recover and died whilst in the intensive care unit. The Royal College of Emergency Medicine (RCEM) fully supports: • adequate staffing for Resuscitation Areas (one registered nurse for each patient and two nurses for cardiac arrests) • multi-speciality and multidisciplinary simulation training between departments (including failed or difficulty airway drills) • standardisation of equipment between critical areas, including difficult airway trolleys • • the use of intubation checklists the use of capnography both in the resuscitation area and for transport monitors These and other standards and recommendations currently form part of an existing document which provides a framework for collaborative working between Emergency Medicine (EM) and Intensive Care Medicine (ICM) [1]. As a specialty 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. Yours sincerely, Chair, Quality in Emergency Care Committee 1. BETTER TOGETHER: Collaborative working between Emergency and Critical Care. COLLABORATIVE WORKING BETWEEN EMERGENCY AND CRITICAL CARE. July 2021 https://rcem.ac.uk/wp-content/uploads/2021/10/RCEM_FICM_Better_Together_Framework.pdf
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