Peter Saint

Coroner's concerns

AI summary

A lead anaesthetist's misunderstanding of physiology led to misinterpretation of capnography during resuscitation, resulting in unrecognised oesophageal intubation, a known issue not adequately addressed since 2011.

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The MATTERS OF CONCERNS are as follows: (a) the course of evidence heard that an (admitted) "misunderstanding of physiology" led the 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 45 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 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_ (b) 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 During during into the patient; observes the capnography for a period of up to 15 to 20 seconds to ensure that a "proper CO2 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:

Responses

3 respondents

Royal College of Anaesthetists Education

2 Jan 2018 PDF

Action Planned

The RCoA, AAGBI and DAS will publish articles and highlight the importance of capnography in the Safe Anaesthesia Liaison Group's Patient Safety Update, Anaesthesia News and the DAS newsletter. The RCoA's Simulation Working Group will consider creating guidance on crisis simulation for operating theatre teams. (AI summary)

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Dear Mr. Horstead, Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Peter Ian SAINT Thank YoU for giving the Royal College of Anaesthetists (RCoA) the opportunity to respond to your Regulation 28 Report. The RCoA has collaborated with the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the Difficult Airway Society (DAS) in preparing this response_ Capnographx We are concerned that despite the emphasis placed upon the continuing presence of exhaled carbon dioxide during resuscitation from cardiac arrest in resources such as NAP4 and the Advanced Life Support programme run by the Resuscitation Council UK, there are still clinicians holding senior positions in anaesthesia in the NHS who are unaware of this important fact. We will seek to address this issue by: Bringing this to the attention of all trainees in anaesthesia in the UK, to all Fellows and members of the RCoA, to all members of the AAGBI and all members of the DAS and thereby to the overwhelming majority of practising anaesthetists in the NHS by publishing an article on this subject in the Patient Safety Update published quarterly by the Safe Anaesthesia Liaison Group (SALG): hlps [cod9sklscl, by highlighting this issue in a "Safety Matters article in Anaesthesia News (a publication that is circulated to over 11,000 AAGBI members) and in the DAS newsletter. Bringing this to the attention of RCoA and DAS Airway Leads (AWLs) , present in every NHS Trust /Board, at the next national AWL meeting inviting feedback on areas for improving training those charged with providing the RCoA '$ comprehensive online educational programme (e-Learning for Anaesthesia) to consider highlighting this issue in sessions on intubation, capnography and resuscitation: Human factors and teamwork The RCoA agrees with the expert who advised YoU during the inquest that there is a lack of widespread, regular, mandatory training for clinicians in human factors and crisis drills. The RCoA supports such education, running & regular programme of training in "Non-Technical Skills" httpsLLWWWIcoqacUkIsitesldefaultlfilesk24 LL 1 Opdf and working group devoted to providing guidance on simulation of clinical crises, while including @ requirement for human factors training in its exam curricula and its Guidelines for the Provision of Anaesthesia Services. We note that regular human factors and teamwork training for multidisciplinary groups is & requirement of the recently published National Safety Standards for Invasive Procedures (NatSSIPs) , which are being introduced in England and Wales. The RCoA cannot mandate multidisciplinary training in NHS working environments, it is the responsibility of health organisations to facilitate this in terms of time and resources, but the RCOA will take the following actions to support this development: Asking the RCoA '$ Simulation Working Group to consider creating guidance on how departments of anaesthesia can introduce regular crisis simulation for operating theatre teams_ Collcge = Asking

RCOA Difficult Airway Society THE AsSOCIATION OF ANAESTHETISTS of Anaesthetists of Great Britain & Ireland Working with the AAGBI to promote regular multidisciplinary crisis simulation when it publishes its forthcoming Quick Reference Handbook, @ series of national guidance documents on the management of emergency situations in anaesthetic practice. This handbook emphasises the importance of multidisciplinary crisis practice and the significance of the absence of ETCO2 in cardiac arrest_ Working with the DAS, who have set up an expert working group looking specifically at human factors in airway management;, to address the non-technical aspects of management of tracheal intubation and difficult airways: hope that these actions will satisfy YoU that the named organisations are taking appropriate steps to ensure that anaesthetists are aware of these issues and that the circumstances that led to the death of Mr Saint are therefore less likely to occur again: would be happy to respond to any questions that YoU might have_

North West Anglia NHS Trust NHS / Health Body

12 Jan 2018 PDF

Action Planned

North West Anglia NHS Foundation Trust is planning simulation training for anaesthetists, commissioning human factors training, and undertaking a SCORE cultural survey, with a timescale for completion by the end of March 2018. Since June 2016, many substantive appointments have been made to the cadre of Consultant Anaesthetists at Hinchingbrooke Hospital. (AI summary)

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Dear Mr Horstead Regulation 28: Report to prevent future deaths Thank you for the Regulation 28 letter received in November 2017 in relation to the death of Mr Peter Saint: May take this opportunity on behalf of North West Anglia NHS Foundation Trust to assure you that we acknowledge the shortcomings in our care of Mr Saint and fully appreciate your concerns _ Your letter has been circulated amongst the Anaesthetic clinical and leadership complement at the entire Trust;, that is to say Hinchingbrooke and Peterborough City Hospitals An action plan has been developed to tackle not only the technical aspects which were identified in the inquest; but also the wider human factors and cultural issues that were exposed. The points below set out our proposed action plan, with a timescale for completion by the end of March 2018. Simulation training AIl 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: It is a one course for anaesthetist-ODP teams that combines human factors with airway technical skills_ It includes interactive team training, simulation, erro avoidanca strategy, airway-technical skils ,human factors in crisis management and practical briefingidlebriefing skills Due to the logistics 0f having all of the anaesthetists attending-exrernan while continuing to staff the service for patients it will be necessary to run the course on Frainipge dates. This course will address the specific issues regarding the use and interpretation of capnography that were raised in your letter_ Human factors training consultant obstetrician expertise in Human Factors has been commissioned to provide training to anaessheasts andetheatre staff. Multidisciplinary teams, consisting of consultant anaesthetists, operating practitioners theatre nurses, are being recruited. These teams will be trained to train, foloaringemhichcheoneiti &eigeneaainingrseother siatr on & rolling basis throughout the vear A steering composed of the Associate Divisional Director (consultant anaesthetist), matrons and theatre group, City day with and

managers, will meet 3-monthly to consider recommendations from the trainer group. This will address the non-technical issues that were involved in causing the death. SCORE cultural survey (Safety, Communication, Operational Reliability & Engagement) This survey has been undertaken among six teams at Hinchingbrooke, including anaesthetists and theatre staff. Feedback occurs in a controlled environment that provides a safe forum for staff to discuss issues, in the absence of managers and management grade clinicians_ The feedback session for anaesthetists took place on 12 December 2017_ The process for collating comments is currently underway: When this is complete it will generate a further action plan for managers_ This will address wider organisational issues that may have contributed indirectly to the circumstances that led to the death: would add that since the unfortunate event of June 2016, many substantive appointments have been made to the cadre of Consultant Anaesthetists at Hinchingbrooke Hospital to replace locum staff: addition, there is now circulation of colleagues between Peterborough and Hinchingbrooke Hospitals delivering clinical sessions at both sites, allowing a greater pool of mutual support, mentorship, training and access to best practice. once again assure you that take this issue extremely seriously and will do my upmost to ensure similar events never happening again: Kind regards.

NHS England NHS / Health Body

7 Jun 2018 PDF

Action Taken

NHS Improvement added 'undetected oesophageal intubation' to their Never Event Framework in February 2018, and is developing national guidance in collaboration with relevant organisations. The RCoA's CPD includes training on perioperative emergencies and human factors. (AI summary)

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Dear Mr Horstead , Re: Regulation 28 Report to Prevent Future Deaths following an inquest concerning the death of Peter Ian Saint (died 28.06.2016) Thank you for your Regulation 28 Report to Prevent Future Deaths ("Report") dated 17 November 2011 concerning the death of Mr Saint on 28th June 2016. Firstly, would like to express my deep condolences to Mr Saint's family. We would also like to apologise for the late response to your Report; your Report was not received in time for me to form a response within the 56 days' timescale Your Report concludes Mr Saint's death was a result of extensive hypoxic brain damage sustained when deprived of effective lung ventilation after an endotracheal tube was incorrectly located in his oesophagus whilst under general anaesthetic for routine knee replacement surgery . Following the inquest you raised concerns in your Report to NHS England regarding: a) a failure to understand capnography indications b) a lack of on-going training for anaesthetists NHS England is the national commissioning board for the NHS: We set national NHS priorities, provide direction and share out funds to local areas to deliver healthcare. Whereas, NHS Improvement has responsibility for overseeing foundation trusts and NHS trusts to ensure and to hold to account all providers on quality of care and on financial stability. As a result; we do not communicate directly with NHS hospital trusts. However, we have contacted colleagues within the patient safety team at NHS Improvement who have contacted North West Anglia NHS Foundation Trust ("Trust") directly: The Trust has confirmed that a Serious Incident Investigation Report has been carried out. concluded that: endotracheal tubes and 2 were incorrectly placed in the oesophagus rather than the trachea. Contributing High quality care for all, now and for future generations June They

to this was the failure to recognise this resulted in prolonged loss of the airway, oxygenation and subsequent cardiorespiratory arrest and hypoxic brain injury: The leadership of the cardiac arrest was poorly managed due to loss of situational awareness and human factors: There was a reliance on the clinical signs of tube placement rather than on the monitoring equipment and capnography readings'. We also note that the Trust has contacted the family to notify them of this investigation NHS Improvement has also informed us that further action has been taken around this matter in that; as of February 2018,a new Never Event 'undetected oesophageal intubation has been included into their Never Event Framework_ The Framework lists out a number of events that are defined as 'serious incidents' as are deemed preventable as sufficient national guidance does exist and should be implemented by all healthcare providers NHS Improvement is currently developing the national guidance required to support this proposed new Never Event; working closely with relevant national organisations, including Royal College of Anaesthetists ("RCoA") , the Association of Anaesthetists of Great Britain and Ireland ("AAGBI") and British Association of Paediatric Nephrology (the Renal Association): In terms of training, the RCoA's continuing professional development' ("CPD") does include training on perioperative emergencies (including crisis training); emergency management and resuscitation; and human factors in anaesthetic practice: Consultants must undertake CPD training and this is used to assess revalidation, which every doctor practising medicine in the United Kingdom must do. We believe that the additional development of national guidance under the Never Events Framework will further support this. Thank you for bringing these important patient safety issues to my attention and hope the above information has provided you with assurances that NHS England is taking appropriate action to address your concerns. Please do not hesitate to contact me should you need any further information.

Report sections

Investigation and inquest

On 07/07/2016 an investigation was commenced into the death of Peter Ian SAINT aged 71. The investigation concluded at the end of the inquest on 23/10/2017. The conclusion of the inquest was: Medical cause of death: la Hypoxic ischaemic brain damage following oesophageal placement of endotracheal tube; 1b General anaesthesia for knee replacement surgery: There was a narrative conclusion that Mr Saint "died from extensive hypoxic brain damage sustained when deprived of effective lung ventilation after an endotracheal tube was located in his oesophagus for @ period of some 25 minutes whilst under general anaesthetic for routine knee replacement surgery:

Circumstances of the death

On the 23"d June 2016 Peter Saint, a 71 year old man was admitted to Hinchingbrooke Hospital, Cambridgeshire for routine elective knee replacement surgery: General anaesthesia was administered at around 15.00 hours. Between 15.40 and 15.45 hours there was a progressive fall in Mr Saint's arterial oxygen saturation and an increase in ventilation pressure: At the removal of the laryngeal mask airway gastric fluid was expelled; the operating table was tilted head down, suction applied and an i-Gel airwav deploved. At around 16.00 hours the i-Gel was replaced by an endotracheal intubation tube However, this was inserted into Mr Saint'$ oesophagus rather than his trachea. The oesophageal placement was not identified by the three anaesthetists present (including two consultants), notwithstanding the fact that an experienced Senior Operating Department Practitioner specifically raising his concerns that the intubation tube was misplaced by reference to the capnography which indicated an absence of a CO end tidal wave on the monitor and the apparent "timpanic" distension of the patient's stomach. At or around 16.04 hours Mr Saint suffered a cardiac arrest and chest compressions were commenced. The oesophageal placement of the endotracheal tube was only confirmed at or around 16.25 hours and the intubation tube was relocated in the trachea_ For a period of around 38 minutes, from approximately 15.47 hours until 16.25 hours Mr Saint received no effective lung ventilation. For some 25 minutes of that 38 minute period the endotracheal intubation tube was incorrectly located in Mr Saint'$ oesophagus Throughout, confirmation that Mr Saint was receiving no effective lung ventilation was displayed on the monitoring equipment as an absence ofany CO2 end tidal wave consistent with effective lung ventilation, together with a digital read out of 'zero' immediately adjacent to the CO2 end tidal wave display: Mr Saint was transferred to the Intensive Care Unit (ICU) of Hinchingbrooke Hospital where he died at 13.44 hours on 28 June 2016_

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:

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