NHS England
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Source · Prevention of Future Deaths
Linda Green
Ref: 2026-0360
Date: 11 Jun 2026
Coroner: Mary Hassell
Area: Inner North London
1 response identified · 1 indexed addressee
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Response deadline: 6 August 2026 (stated in the report).
Date
11 Jun 2026
56-day deadline
6 Aug 2026
stated in the report
Responses identified
1 of 1
Coroner's concerns
I was told at inquest that, at the time of Ms Green’s death, there were only 6 hyperbaric oxygen chambers in the country and none in London. I heard that considerable time was spent by staff at the Whittington Hospital trying to locate their nearest unit.
View full coroner's concerns
I was told at inquest that, at the time of Ms Green’s death, there were only 6 hyperbaric oxygen chambers in the country and none in London. I heard that considerable time was spent by staff at the Whittington Hospital trying to locate their nearest unit.
There had been a unit in East London at Whipps Cross Hospital, and this appeared online to be operational. However, the staff eventually discovered that this had been decommissioned. This was when they approached the James Paget Hospital in Great Yarmouth. I heard that, as a result of Ms Green’s death, the unit at Whipps Cross Hospital has re-opened temporarily for one year. However, Ms Green’s treating consultant anaesthetist gave evidence at inquest that she did not know this.
Resourcing decisions about which hyperbaric oxygen chambers to close, keep open or re-open are of course not within the remit of a Coroner’s Court. However, it seems to me that as an absolute minimum, all relevant healthcare professionals should be able easily to access information about the location of the nearest operational unit.
There had been a unit in East London at Whipps Cross Hospital, and this appeared online to be operational. However, the staff eventually discovered that this had been decommissioned. This was when they approached the James Paget Hospital in Great Yarmouth. I heard that, as a result of Ms Green’s death, the unit at Whipps Cross Hospital has re-opened temporarily for one year. However, Ms Green’s treating consultant anaesthetist gave evidence at inquest that she did not know this.
Resourcing decisions about which hyperbaric oxygen chambers to close, keep open or re-open are of course not within the remit of a Coroner’s Court. However, it seems to me that as an absolute minimum, all relevant healthcare professionals should be able easily to access information about the location of the nearest operational unit.
Responses
Report sections
Investigation and inquest
On 17 December 2025, I commenced an investigation into the death of Linda Green, aged 66 years. I concluded the inquest on 8 June 2026. I recorded a medical cause of death of: 1a hypoxic-ischaemic brain injury 1b cerebral air embolism 1c oesophageal mucosal tear complicated by pneumomediastinum following elective oesophageal balloon dilatation (21/11/25) 1d severe lymphocytic oesophagitis with stricture 2 rheumatoid arthritis
Circumstances of the death
Linda Green died as a result of a complication of medical treatment. She underwent an oesophageal balloon dilatation at 9.30am on 21 November 2025 at the Whittington Hospital in London. This lasted approximately 10 minutes. Unbeknown at the time to those treating her, the procedure caused an oesophageal perforation that resulted in a cerebral air embolism. This led to her not waking up from the anaesthetic and ultimately killed her.
The perforation and pneumocephalus were diagnosed at 1.30pm. She did not leave the hospital for transfer to a hyperbaric oxygen unit until 6pm. She died the following day at the James Paget University Hospital in Great Yarmouth.
The perforation and pneumocephalus were diagnosed at 1.30pm. She did not leave the hospital for transfer to a hyperbaric oxygen unit until 6pm. She died the following day at the James Paget University Hospital in Great Yarmouth.
Action should be taken
In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe that you have the power to take such action.
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Report details
- Reference
- 2026-0360
- Date of report
- 11 June 2026
- Coroner
- Mary Hassell
- Coroner area
- Inner North London
Responses identified
Responses identified
1 of 1
All listed responses identified
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 6 Aug 2026 (stated in the report).
Sent to
- NHS England