Linda Green

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.    She also told me that the Whittington still does not have a pathway for use in such situations. As a starting point, she explained that some anaesthetists  are  unlikely  to  be  aware  that  endoscopists  may  not necessarily know that a perforation has occurred during the procedure, and will not have the potential for pneumocephalus in their thinking.  

It seems to me that all relevant healthcare professionals should have information about the location of the nearest operational  hyperbaric oxygen chamber, and I was told that the trust should have a clear pathway for anaesthetists and gastroenterologists regarding the care and transfer of patients who do not wake up after oesophageal dilatation.