Linda Green

Dear Ms Hassell, Re: Regulation 28: Report to Prevent Future Deaths in the matter of Linda Lucille Victoria Green Thank you for sending us a copy of your report regarding the very sad death of Ms Green. We would like to express our sincere condolences to all those affected by this loss. We have reviewed the information available to us in the report via our Safe Anaesthesia Liaison Group (SALG). SALG is a collaborative project between the Association of Anaesthetists, NHS England’s Patient Safety team and the Royal College of Anaesthetists. One of its core objectives is to analyse anaesthesia-related serious incidents and to share the learning with the specialty across the UK. You expressed concern that “some anaesthetists are unlikely to be aware that endoscopists may not necessarily know that a perforation has occurred during the procedure, and the anaesthetists will not have the potential for pneumocephalus in their thinking.” From analysing the information you provided and other case reports available, it is clear that pneumocephalus can be very challenging to diagnose, particularly when the patient is anaesthetised. Cerebral air embolism can present as failure to wake after general anaesthesia, but if this is the first sign, urgent diagnosis by CT scan and referral for hyperbaric oxygen therapy may improve the chance of recovery. It is important for clinicians to be aware that certain types of endoscopic procedures, including oesophageal balloon dilatation, are associated with a greater risk of air embolism. Raising awareness of such risks is one of the key functions of SALG and we will disseminate the key learning points highlighted through our regular Patient Safety Update publication, which is distributed to all members of the Association of Anaesthetists and Royal College of Anaesthetists. We would be happy to respond to any questions that you might have.