Recurring concern

Unreliable post-operative extubation decision and management

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First reported 28 Jun 2016•Latest report 30 Sep 2019

Definition

What this concern includes

Includes failures in the dedicated post-operative extubation process, including planning and instructions, readiness assessment, consultant or senior review, airway and respiratory support arrangements, monitoring, escalation and response to complications after extubation.

Not included

Excludes general post-operative care, clinical handover or PICU coordination failures where extubation decision-making or management is not the material unsafe condition.
Excludes failures in ventilation, ECMO or respiratory support that are unrelated to deciding on or managing extubation.
Excludes failures occurring after an adequately planned, reviewed and safely completed extubation when the remaining problem is unrelated downstream care.
Excludes generic staffing, training, communication or documentation deficiencies unless they directly impair the post-operative extubation process.

Reports: 2
Individual concerns: 2
Date range: 2016–2019
Stated actions: 2

Reports 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

Great Ormond Street Hospital for Children NHS Foundation Trust1

Parents of Tommi-Ray Colin Vigrass1

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.

30 Sep2019
London Inner (North)
Concerns raised1
1. Lack of a clear post-operative extubation plan or instruction
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Develop, test and launch a standardised electronic anaesthetic-to-ICU handover document with accompanying training.
  Stated by Great Ormond Street Hospital for Children NHS Foundation TrustStated in progress
2. Action
  Publish and use a spinal surgery pathway guideline defining responsibilities for complex cardiac patients admitted to PICU.
  Stated by Great Ormond Street Hospital for Children NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Extubation plans appropriately evolve with the patient’s condition, with the PICU Consultant responsible for decisions and communicating the plan.
  Stated by Great Ormond Street Hospital for Children NHS Foundation TrustDisputes the concern
AI-generated summary

Amy Allan · 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

Amy Allan underwent elective corrective spinal surgery on 4 September 2018 and subsequently suffered severe deterioration, requiring ECMO support before dying on 28 September 2018. Concerns included inadequate pre-operative planning for ECMO, poor communication and handover between departments, extubation while her condition was deteriorating, delayed ECMO support, and a lack of clear co-ordination of her post-operative care.

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
Lack of a clear post-operative extubation plan or instruction
Wider context from the report
“I am concerned that: (a) It appears there was a lack of awareness and sharing of information between departments at Great Ormond Street Hospital. In particular, the PICU had not been given any advance warning of Amy’s complex medical background and needs before she was admitted there post operation. As PICU staff were not invited to the Multi-Disciplinary Team meetings prior to the operation, they were not aware of the “critical time” which lay ahead for her; (b) There was no clear plan or instruction for the management of Amy post operation in relation to extubation and ECMO support on the PICU; (c) The handover between clinicians involved in Amy’s operation and those taking over her care in the PICU, was poorly executed with vital information either not properly conveyed or recorded or simply missed; (d) There was a delay in commencing ECMO support, and (e) No single properly informed clinician appeared to be co-ordinating Amy’s post-operative care in such a complex and high risk case. ”
Source location
Amy Allan · Prevention of Future Deaths report
Page 3 · 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
Develop, test and launch a standardised electronic anaesthetic-to-ICU handover document with accompanying training.

Verbatim wording from the response
“The Electronic Patient Record department is currently supporting the Anaesthetic and ICU teams to develop a standardised electronic handover document which mirrors the paper form which has been developed for this purpose. The electronic handover document will ensure that all the relevant fields are together in one section so that they can be clearly and easily discussed as part of a structured verbal handover, and act as an ongoing plan to support the ICU team.”

Source location
2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
Page 5 · response
Published 13 November 2019
Open published response
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
Publish and use a spinal surgery pathway guideline defining responsibilities for complex cardiac patients admitted to PICU.

Verbatim wording from the response
“To ensure that all staff members involved in the care are clear about the pathway, and their roles and responsibilities within that pathway, the PICU Consultant Team have now developed a guideline on the spinal surgery pathway for complex cardiac patients admitted to PICU. A copy of this guideline is enclosed [Spinal Surgery Pathway PICU FINAL].”

Source location
2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
Page 8 · response
Published 13 November 2019
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
Extubation plans appropriately evolve with the patient’s condition, with the PICU Consultant responsible for decisions and communicating the plan.

Verbatim wording from the response
“The plans and instructions for management of extubation are guided by the patient’s consultant anaesthetist on the basis of the patient’s response to the general anaesthetic on the day of the procedure. This means that the handover between the anaesthetic and PICU team is a crucial safety mechanism. The changes which the Trust has made in relation to the anaesthetic-PICU handover are outlined in paragraph (c).”

Source location
2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
Page 4 · response
Published 13 November 2019
Open published response
28 Jun2016
Black Country
Concerns raised1
1. Failure to consult the on-call consultant before making extubation decisions
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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 consult the on-call consultant before making extubation decisions
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of a clear post-operative extubation plan or instruction

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to consult the on-call consultant before making extubation decisions

Actions described in response 2

Respondent positions 1