“S are as follows: (a) During the course of evidence | heard that an (admitted)…”

The coroner’s concerns

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S are as follows: (a) During the course of evidence | heard that an (admitted) “misunderstanding of physiology” led the (b) lead consultant anaesthetist involved in the treatment of Mr Saint to conclude that whilst the patient was receiving appropriate chest compressions during resuscitation efforts, the capnography indicating an absence of a CO2 end tidal wave on the monitor could be explained by the fact that Mr Saint was in cardiac arrest. This was a mistake since exhaled CO2 can virtually always be observed during cardiac arrest with correctly applied compressions and lung ventilation. The clear expert evidence was that, discounting a technical problem with the monitoring equipment (not applicable here), the absence of a proper CO2 end tidal wave could only in the most exceptional circumstances be accounted for by anything other than oesophageal intubation and certainly not by cardiac arrest. Further, the expert evidence indicated that such a “misunderstanding of the physiology” is one that is known to be shared by other anaesthetists. This is of particular concern given that the issue was specifically addressed in the 4" National Audit Project (NAP4) of the Royal College of Anaesthetists and the Difficult Airway Society: ‘Major Complications in Airway Management in the UK’ Report and Findings as long ago as March 2011 (at page 101): “Unsurprisingly, the outcome of unrecognised oesophageal intubation is usually very poor indeed. Tracheal intubation in theatre is nowadays carried out in the presence of a trained assistant and a tested and functioning capnograph. The latter, in particular, means that unrecognised oesophageal intubation rarely occurs in the theatre environment. In contrast to the ICU and emergency department cases where capnography was not used, in the cases of oesophageal intubation during anaesthesia capnography was in use during the event. The event progressed due to failure to correctly interpret capnography in the face of situations of peri-arrest or cardiac arrest. Capnography can become difficult to interpret during low cardiac output states and in cardiac arrest. However a flat line is not usual and even in cardiac arrest, during CPR, carbon dioxide is produced leading to an attenuated but visible capnography trace (see Figure 1). A completely flat capnograph in any circumstances should immediately raise the possibility that the tracheal tube is not in the trachea, or is obstructed. Active measures should be undertaken to confirm or exclude these diagnoses. Clinical signs are unreliable in these circumstances and it is recognised that oesophageal intubation may present both after apparent normal auscultation of the lungs and as cardiovascular collapse.” (Emphasis added). The Report made the following recommendation: “Training of all clinical staff who may intubate patients should include interpretation of capnography. Teaching should include recognition of the abnormal (but not flat) capnography trace during low cardiac output states and during cardiopulmonary resuscitation.”(page 103). am concerned that the evidence in this case, including the expert evidence, established that notwithstanding the findings and recommendations of the 2011 NAP4 there is a continuing failure to ensure that capnography is sufficiently understood and utilised by all clinical staff who may intubate patients. The evidence heard, including the expert evidence, confirmed that an integral part of the process of intubating a patient requires that the anaesthetist, following the placement of the intubation tube into the patient, observes the capnography for a period of up to 15 to 20 seconds to ensure that a “proper CO2 end tidal wave” can be detected; failure to do so would be a “fundamental and basic error” and a “serious error”. | am concerned that this procedure was not followed by either the lead consultant anaesthetist in this case or the anaesthetists who attended to assist him. The expert evidence indicated a lack of widespread, regular, mandatory on-going training for anaesthetists in drills dealing with crisis situations potentially facing an anaesthetic team particularly in relation to the issues of “task fixation” and “confirmatory bias”, and that such training would be beneficial. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you (and/or your organisation) 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 12" January 2018. |, the coroner, may extend the period.

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, 2017-0404

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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