“ There is limited evidence to date for the introduction and continuing use of…”

The coroner’s concerns

–  There is limited evidence to date for the introduction and continuing use of comprehensive airway strategies, with structured planning and preparation, when a difficult airway is anticipated. There should be airway plans A, B, and C recorded, shared, and the equipment and skills to carry them out must be available  There is limited evidence to date for the universal use of the NAP4 algorithms and checklists, which should be available on the difficult airway trolley, and be familiar to all ICU nursing and medical staff, and to the wider anaesthetic team  There is limited evidence to date, for the robust daily checking of all necessary equipment on the difficult airway trolley, to ensure immediate replacement of all key equipment if it is broken or misplaced  The Mortality Review policy was not followed, leading to a significant delay in completing the serious incident review, delaying Trust learning, and delaying the family’s understanding of the circumstances of Jodie’s death. There is limited evidence of progress in implementing the national Patient Safety Incident Response Framework at the Trust I am not reassured that necessary actions to address these serious issues identified are in place.

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, 2023-0131

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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