Authors:
- Dr Natalie Silvey, ST7 Anaesthetics, London School of Anaesthesia; DAS Trainee Representative
- Dr Moon-Moon Majumdar, ST5 Anaesthetics, London School of Anaesthesia; DAS Trainee Representative
- Dr Abhijoy Chakladar, Consultant Anaesthetist, University Hospitals Sussex NHS Foundation Trust; DAS Surveys Co-ordinator
- Dr Barry McGuire, Consultant Anaesthetist, Ninewells Hospital and Medical School, Dundee; DAS Immediate Past President
‘Her death was wholly avoidable and was contributed to in major part by neglect.’
This was the conclusion of the coroner examining the death of Mrs Glenda Logsdail following her death from hypoxic-ischaemic encephalopathy after an unrecognised oesophageal intubation.
Her death, like those of Sharon Rose Grierson and Peter Saint in 2016, has placed this issue at the forefront of safety strategy within the anaesthetic community. Following Glenda Logsdail’s death, the coroner issued a Regulation 28 report to prevent future deaths: several teaching aids and educational materials were released in the subsequent six months. We wanted to establish what was being done in individual departments to prevent unrecognised oesophageal intubation.