Unrecognised oesophageal intubation and unconfirmed tracheal tube placement
NHS England received 2 coroners' reports about this hazard between 17 Nov 2017 and 19 Jul 2024.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“During the course of evidence | heard that an (admitted)”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗
“The Trust has confirmed that a Serious Incident Investigation Report has been carried out. They concluded that: 'endotracheal tubes 1 and 2 were incorrectly placed in the oesophagus rather than the trachea. Contributing High quality care for all, now and for future generations to this was the failure to recognise this resulted in prolonged loss of the airway, oxygenation and subsequent cardiorespiratory arrest and hypoxic brain injuiry.”
Stated timescale: February 2018
- 6 years 8 months laterIdentical hazardConfidence 0.90 · higha different coroner
“(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.”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2017 → 2024Joseph Parker6 years 8 months after Peter Saint · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that reliance on capnography is essential to detect oesophageal intubation and that a misunderstanding of its significance can lead to missed esophageal placement.
Peter Saint · 17 Nov 2017
“During the course of evidence | heard that an (admitted)”
Original on judiciary.uk ↗ Joseph Parker · 19 Jul 2024
“(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.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“All members of the anaesthetic department at Hinchingbrooke are to participate in an airway simulation course at a high fidelity simulation centre. We have identified a suitable course and are in the process of planning training with the course provider.”
Stated action · timescale: February 2018
“The Trust has confirmed that a Serious Incident Investigation Report has been carried out. They concluded that: 'endotracheal tubes 1 and 2 were incorrectly placed in the oesophagus rather than the trachea. Contributing High quality care for all, now and for future generations to this was the failure to recognise this resulted in prolonged loss of the airway, oxygenation and subsequent cardiorespiratory arrest and hypoxic brain injuiry.”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2017 → 2024 | 0.80 | 0.33 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.