Joseph Parker: Prevention of Future Deaths Report
Hospital Death (Clinical Procedures and medical management) related deaths
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Date of report: 19/07/2024
Ref: 2024-0389
Deceased name: Joseph Parker
Coroner name: M.E. Voisin
Coroner Area: Avon
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Royal College of Anaesthetists | Faculty of Intensive Care Medicine | Royal College of Emergency Medicine | NHS England
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Royal College of Anaesthetists (RCOA) Faculty of Intensive Care Medicine (FICM) Royal College of Emergency Medicine (RCEM) NHS England | |
| 1 | CORONER I am M. E. Voisin HM Senior Coroner for Avon |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 3 | INVESTIGATION and INQUEST On 21/4/22 an investigation into the death of Joseph Lawrence Parker was commenced. The investigation concluded at the end of the inquest on 4/5/24. The conclusion of the inquest was a narrative, recorded as follows: “The deceased Joseph Lawrence PARKER died on 16 April 2022 at Southmead Hospital. On 17th February 2022 he had taken an overdose of medication which caused his collapse. He was taken to hospital and required intubation. During the procedure the tube was accidentally positioned in the oesophagus, this accidental misplacement should have been identified due to the volume of vomit coming from the tube and the lack of a recognisable capnograph at that time. Once accidental osophageal intubation was recognised he was correctly intubated. The incorrect placement caused him to suffer a cardiac arrest, which led to hypoxic encephalopathy and his death.“ |
| 4 | CIRCUMSTANCES OF THE DEATH On 17th February 2022 Joe’s parents couldn’t wake him, so called 999. The first paramedic was on scene at 07.16hrs. Joe was unconscious, but not in cardiac arrest, his oxygen levels were low at 12, he could see evidence of vomit, an oropharyngeal airway was put in and his oxygen levels went up to 48%. Joe vomited and they had to suction his airway. Joe was taken to Southmead Hospital. During the journey Joe confirmed he had taken and an unidentified tablet. The Consultant in Emergency Medicine, [REDACTED], confirmed that after Joe arrived, and following a rapid assessment of him, colleagues from the Intensive care unit were called as Joe needed to be intubated. [REDACTED], attended from the intensive care unit to carry out the intubation, he called his colleague [REDACTED] to assist and to supervise the intubation. Joe was pre-oxgenated. Intubation began at around 9.37am. Video laryngoscope was used to view the chords, both [REDACTED] and [REDACTED] said that the chords could be viewed. [REDACTED] then inserted the bougie into the airway, both doctors said that they saw the bougie enter the windpipe, [REDACTED] then inserted the breathing tube, by railroading it over the bougie, as he did this it became stuck on cartilage which meant that he had to rotate the tube, the bougie was then taken out, and the cuff was inflated. The tube was not tied in and he accepted that it should have been done immediately. It appears from the evidence that both [REDACTED] and [REDACTED] checked the capnograph at this point to check for an end tidal trace. [REDACTED] said he didn’t know how many, but that he had confirmed tube placement, he added that he didn’t think he would ever have confirmed without seeing at least 3; [REDACTED] said we saw 3 breaths on the monitor. [REDACTED] also referenced the other indicators which were: chest wall movement, breath sounds in the chest, fogging in the tube. He accepted that on their own they are unreliable but that they supported the view that the tube was in the right place. [REDACTED] said that she would have been looking at the monitor as well and she thinks she saw a few end tidal carbon dioxide traces 2 or 3. What is clear from the evidence is that at the time there was no standard guidance on what the requirement was in relation to the capnography. At the time the campaign was no trace wrong place. What happened next and the exact sequence of events varied slightly between the witnesses. There was aspirate/vomit which resulted in suctioning of the airway which I am told was not unexpected, as they were aware that Joe had previously vomited. The aspirate then quickly became larger volumes of vomit. Both doctors accepted that with hindsight the amount of vomit was too much to come from the lungs. During this time Joe’s oxygen levels were dropping and he was heading to cardiac arrest so he called for back-up from [REDACTED], Consultant in Anaesthesia and Intensive Care Medicine. Joe went into cardiac arrest, at around 9.41am, chest compressions were started, advanced life support was given. When [REDACTED] arrived, he noted no trace on the capnograph and asked if the tube was in the right place, he said, because of the uncertainty, he looked with the laryngoscope and saw that it was in the osopahagus, he took it out and put in a new tube. Return of spontaneous circulation was achieved after Joe had been correctly intubated at around 9.48 – 9.49am Joe was taken to the intensive care unit but unfortunately did not recover due to a significant brain injury. [REDACTED], Specialist in Intensive Care Medicine and Anesthetist provided his expert opinion, of note he said: The initial cause of Joe’s neurological decline was the opiate overdose, with initial early recovery due to the actions of the ambulance staff. He continued to have impaired respiratory function but his respiratory rate was normal with low oxygen saturations. Once at the emergency department the decision was made to intubate. That the tube was found to be in the oesophagus, this is a recognized complication. It was after accidental oesophageal intubation that Joe went into cardiac arrest. That it was during the cardiac arrest that the hypoxia caused the brain injury. That the standard at the time was to see a recognisable waveform trace on the capnograph. That if the tube is in the oesophagus you can still get some trace. He agreed that they needed to pass suction to deal with the aspirate which was expected, but that the volume of vomit was not questioned, he said that it is a much smaller volume of vomit that would be in the airways, That the time when the clinicians should have focused most attention on the end tidal trace is after intubation and then if not progressing as expected to re-assess the end tidal trace. It is unlikely that there was a recognizable capnograph trace in this case. So recognition of the accidental oesophageal intubation should have occurred relatively early, but in this case did not. That the volume of vomit should also have triggered a suspicion of accidental oesophageal intubation. That they should have re-intubated, which would have meant that the period of hypoxia would have been transient and would not have resulted in Joe’s death. |
| 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: Both [REDACTED] and [REDACTED] who were involved with this case have written to me supporting that a PFD report should be written in this case. (1) I have been told that capnography is the only reliable test, the gold standard, to confirm that a tracheal tube is in the right place, that no other test should override it. (2) That the more recent PUMA (Project for Universal Management of Airways) guidelines states, the detection of sustained exhaled carbon dioxide using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. The PUMA guidance deserves the widest possible endorsement and dissemination which has not happened yet. (3) Unrecognised oesophageal intubation was a “Never Event” by NHS England but is no longer. (4) There have already been a number of Prevention of Futures Deaths Reports written by Coroner’s in relation to this concern but to date, I am told there have been no changes. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th September 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the chief coroner and to the following interested persons: Family of the deceased North Bristol NHS Trust [REDACTED] South Western Ambulances Service Trust I have also sent a copy to [REDACTED]. I am also under a duty to send the chief coroner a copy of your response. The chief coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the chief coroner. |
| 9 | 19.7.24 M. E. Voisin HM Senior Coroner for Avon |