“I was told at inquest that, at the time of Ms Green’s death, there were only 6 hyperbaric…”

The coroner’s concerns

I was told at inquest that, at the time of Ms Green’s death, there were only 6 hyperbaric oxygen chambers in the country and none in London. I heard that considerable time was spent by staff at the Whittington Hospital trying to locate their nearest unit. There had been a unit in East London at Whipps Cross Hospital, and this appeared online to be operational. However, the staff eventually discovered that this had been decommissioned. This was when they approached the James Paget Hospital in Great Yarmouth. I heard that, as a result of Ms Green’s death, the unit at Whipps Cross Hospital has re-opened temporarily for one year. However, Ms Green’s treating consultant anaesthetist gave evidence at inquest that she did not know this. She also told me that the Whittington still does not have a pathway for use in such situations. As a starting point, she explained that some anaesthetists are unlikely to be aware that endoscopists may not necessarily know that a perforation has occurred during the procedure, and will not have the potential for pneumocephalus in their thinking. It seems to me that all relevant healthcare professionals should have information about the location of the nearest operational hyperbaric oxygen chamber, and I was told that the trust should have a clear pathway for anaesthetists and gastroenterologists regarding the care and transfer of patients who do not wake up after oesophageal dilatation. 10 COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every interested person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. 3 I have sent the report to: the family of Linda Green NHS England Royal College of Anaesthetists Association of Anaesthetists. I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 5 above for additional information relating to the publication of reports and responses. SIGNATURE ME Hassell 4

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0362

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0