Royal College of Anaesthetists
Received
No AI summary available.
Source · Prevention of Future Deaths
Linda Green
Ref: 2026-0361
Date: 11 Jun 2026
Coroner: Mary Hassell
Area: Inner North London
1 response identified · 2 indexed addressees
View PDF
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 2
Coroner's concerns
I heard at inquest that there is no nationally agreed pathway for use in such situations. As a starting point, I was told, 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...
View full coroner's concerns
I heard at inquest that there is no nationally agreed pathway for use in such situations. As a starting point, I was told, 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.
It was put to me that there should be a clear pathway for anaesthetists and gastroenterologists regarding the care and transfer of patients who do not wake up after oesophageal dilatation.
It was put to me that there should be a clear pathway for anaesthetists and gastroenterologists regarding the care and transfer of patients who do not wake up after oesophageal dilatation.
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
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.
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.
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 each of your organisations has the power to take such action.
Similar PFD reports
Report details
- Reference
- 2026-0361
- Date of report
- 11 June 2026
- Coroner
- Mary Hassell
- Coroner area
- Inner North London
Responses identified
Responses identified
1 of 2
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 6 Aug 2026 (stated in the report).
Sent to
- Association of Anaesthetists
- Royal College of Anaesthetists