Recurance · prevention of future deaths reports
Pre-inquest brief
Unrecognised oesophageal intubation and unconfirmed tracheal tube placement
The earlier warning
Peter Saint · 17 Nov 2017 · Sean Horstead, Cambridgeshire and Peterborough
“During the course of evidence | heard that an (admitted)”
What was promised
Stated action 1 · response to Peter Saint (17 Nov 2017) · stated 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.”
What recurred
- 19 Jul 2024 · Joseph Parker · M.E. Voisin · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Peter Saint · 17 Nov 2017
“During the course of evidence | heard that an (admitted)”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.