Recurring concern

Unreliable exhaled carbon dioxide monitoring for neonates

First to latest report 21 Nov 2013 — 28 Jun 2016

Reports that mention this concern: 2
Times this concern has been raised: 2
Stated actions linked to this concern: 1

What this concern includes

Includes failures of dedicated neonatal exhaled-carbon-dioxide monitoring controls, including delayed, omitted or non-routine use of CO2 monitors or disposable ET CO2 detectors during airway management and related neonatal care.

What is not included

Excludes generic physiological monitoring failures where exhaled carbon dioxide monitoring is not the deficient control.
Excludes failures involving adult or non-neonatal patients unless the assertion explicitly concerns the same neonatal ET CO2 monitoring process.
Excludes ventilator, airway or intubation failures where CO2 monitoring is not itself deficient.
Excludes failures limited to interpreting or acting on a reliably obtained CO2 reading.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission1

Department of Health and Social Care1

Parents of Tommi-Ray Colin Vigrass1

Pennine Acute Hospitals NHS Trust1

Pennine Care NHS Foundation Trust1

Walsall Healthcare NHS Trust1

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

28 Jun2016
Black Country
Concerns raised1
1. Failure to use the CO2 monitor early enough
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Walsall Healthcare NHS Trust
Stated actions 1
1. Walsall Healthcare NHS Trust
  Train neonatal staff in difficult-airway management, including CO2 detector use and associated airway equipment.
AI-generated summary

Tommi-Ray Colin Vigrass · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Tommi-Ray Colin Vigrass was born prematurely at 28+2 weeks’ gestation and developed respiratory distress requiring ventilator support. Following difficulties with changing and re-inserting his endotracheal tube, he suffered a hypoxic episode and significant brain damage, and died on 13 January 2016. Concerns included the decision-making around extubation and intubation, delayed contact with the tertiary unit, and inadequate handover and preparation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to use the CO2 monitor early enough
Wider context from the report
“1. Evidence emerged during the inquest that the Paediatric Doctor in charge recognised that it was a mistake to extubate baby when he did. His words were: “What should have been a straight forward ET change turned into a nightmare”. He also confirmed that he should have consulted the Consultant on call prior to making the decision and earlier use of the CO2 monitor would have made a difference. ”
Source location
Tommi-Ray Colin Vigrass · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Train neonatal staff in difficult-airway management, including CO2 detector use and associated airway equipment.

Verbatim wording from the response
“Neonatal staff have now undergone training on ‘Difficult Airway Management’. This includes the use of:”

Source location
2016-0241-Response-by-Walsall-Healthcare-NHS-Trust
Page 2 · response
Published 8 June 2016
Open published response
21 Nov2013
Manchester North
Concerns raised1
1. Failure to routinely use disposable exhaled carbon dioxide detectors on the NNU
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Department of Health and Social Care
Respondent positions 2
1. Department of Health and Social Care
  Staffing, training, governance and clinical issues are local matters that should be addressed by the NHS Trust.
  Redirects responsibility
1. Department of Health and Social Care
  Existing neonatal service care guidance should cover carbon dioxide detectors and paralysing agents, so duplicate national guidance is unnecessary.
  Existing arrangements considered sufficient
AI-generated summary

Jack William PARTINGTON · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jack Partington was born by planned caesarean section on 25 November 2011 and developed breathing difficulties requiring neonatal ventilation. After developing a pneumothorax, he was treated with intubation and ventilation but deteriorated and died on 26 November 2011. Concerns included gaps in neonatal handover and care planning, treatment decisions made without multidisciplinary consultation, lack of routine use of exhaled carbon dioxide detectors, absence of national guidance on paralysing agents and neonatal ventilation, and inadequate monitoring of ventilatory pressure after intubation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to routinely use disposable exhaled carbon dioxide detectors on the NNU
Wider context from the report
“3) That disposable exhaled carbon dioxide detectors (ET CO2) were not routinely used on the NNU (as an adjunct) and that they are not currently/routinely used in many NNUs throughout the country. ”
Source location
Jack William PARTINGTON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Staffing, training, governance and clinical issues are local matters that should be addressed by the NHS Trust.

Verbatim wording from the response
“I note that you have sent a Regulation 28 report to the local NHS Trust for its response. I believe that the issues concerning staffing, staff training, governance and clinical issues are local issues that should properly be addressed by the Trust.”

Source location
2013-0308-Response-by-Department-of-Health
Page 2 · response
Published 21 February 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing neonatal service care guidance should cover carbon dioxide detectors and paralysing agents, so duplicate national guidance is unnecessary.

Verbatim wording from the response
“Guidance on the use of carbon dioxide detectors and the management and administration of paralysing agents to neonates in need of intubation should already be covered in the care guidance of every neonatal service. We do not therefore believe issuing duplicate guidance would be valuable. The Resuscitation Council (UK) has issued updated guidance on new-born life support, which recommends detection of exhaled carbon dioxide in addition to clinical assessment as the most reliable method to confirm placement of a tracheal tube in neonates with a spontaneous circulation. We have been advised by NHS England that carbon dioxide monitors are being used increasingly in neonatal units. However, their use in individual cases is a matter for the clinical judgement of the health professionals involved.”

Source location
2013-0308-Response-by-Department-of-Health
Page 2 · response
Published 21 February 2014
Open published response