“I was concerned to find that the anaesthetising Consultant Anaesthetist was not aware of…”

The coroner’s concerns

– (1) I was concerned to find that the anaesthetising Consultant Anaesthetist was not aware of the Royal College of Anaesthetists campaign video “Capnography in Cardiac Arrest: No Trace = Wrong Place”. (2) 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) As Mrs Logsdail’s 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. 3 (4) As Mrs Logsdail deteriorated Dr erroneously fixated on a diagnosis of anaphylaxis being responsible for the collapse. That fixation was contagious and appeared to compromise the assessments by other staff members who attended to help. Dr did not go back to basics and consider A(airway), B (breathing), C (circulation) to work his way through possible correctable causes. He told me frankly that he became more and more fixated on anaphylaxis as the cause. Despite treatment for anaphylaxis and Mrs Logsdail’s failure to improve he persisted with this as the diagnosis. His certainty in his diagnosis inhibited other staff members from effectively contemplating other causes until the arrival of another Consultant Anaesthetist. I accept entirely that he was not behaving in a dismissive or aggressive manner. He simply conveyed an infectious certainty which hindered other team members challenging him when several could see that Mrs Logsdail was increasingly cyanosed and in desperate straits. (5) There was evidence of an inhibitory hierarchical structure which prevented others shouting out. This is despite the fact that I found Dr to be a mild mannered, gentle and reflective witness. (6) There was panic and chaos in the anaesthetic room. There was considerable confusion as to roles and there was an absence of a leader dealing with the emergency. Dr was the natural leader but I found that he was effectively blind to what needed to be done – to check the capnograph and to reintubate. Individual staff members took on roles independently in the cardiac arrest. That is to be commended on an individual level but it betrays a fundamental lack of direction and control of the situation and bodes poorly for management of future life threatening emergencies. The team malfunctioned and did not operate as a team. (7) The panic and chaos led to an inappropriate delegation of an irrelevant task to a Consultant Anaesthetist who attended to assist who eventually was the one to realise the ET tube was misplaced. This distracted her for a minute or two adding to the time when Mrs 4 Logsdail was not ventilated. (8) I heard that there were variable and different configurations with respect to the displays on the ventilators in different theatres and anaesthetic rooms and ITU through the hospital. This was confusing for staff and had potential to put patients at risk.

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, 2021-0295

Added to Minute Book

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