Recurring concern

Unreliable exhaled carbon dioxide monitoring for neonates

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First reported 21 Nov 2013•Latest report 28 Jun 2016

Definition

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.

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.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2013–2016

First to latest report issue date

Stated actions
1

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

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

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Black Country

    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

  2. Manchester North

    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
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Data last updated 7 September 2026