Recurring concern

Unreliable airway protection during anaesthesia

Get email alerts

Request correction

First reported 11 Jan 2018•Latest report 24 Feb 2025

Definition

What this concern includes

Includes failures of dedicated airway-protection controls during anaesthesia or rapid sequence induction, including clinically indicated cricoid pressure, current guidance on airway-protection measures and comparable controls specifically intended to reduce aspiration risk.

Not included

Excludes general airway assessment, intubation, ventilation or resuscitation deficiencies unless the asserted failure specifically concerns protection against aspiration during anaesthesia.
Excludes generic training, staffing, equipment or documentation deficiencies unless they are directly tied to an airway-protection control during anaesthesia.
Excludes suction or nasogastric-tube failures when they concern treatment of aspiration or gastrointestinal decompression rather than a dedicated airway-protection control.
Excludes airway-protection concerns outside anaesthesia or rapid sequence induction unless the reports explicitly support the same bounded airway-protection system.

Reports: 2
Individual concerns: 3
Date range: 2018–2025
Stated actions: 3

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.

Association Of Anaesthetists (Great Britain & Ireland)1

Care Quality Commission1

Department of Health and Social Care1

Difficult Airway Society1

General Medical Council1

NHS England1

Royal College of Anaesthetists1

Royal College of Emergency Medicine1

Royal College of Physicians1

Royal Stoke University Hospital1

Surrey and Sussex Healthcare NHS Trust1

University Hospitals of North Midlands 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.

24 Feb2025
Surrey
Concerns raised2
1. Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery
2. Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction
This report raised 8 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 3
1. Action
  Share learning from Mrs Marking’s death with members and publish a best-practice statement on RSI.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated planned
2. Action
  Use a modified total intravenous anaesthesia technique with predetermined propofol and muscle-relaxant boluses when performing rapid sequence induction with TIVA.
  Stated by Surrey and Sussex Healthcare NHS TrustStatus unclear
3. Action
  Communicate and reinforce the use of cricoid pressure for rapid sequence induction in bowel obstruction through meetings, induction training, and simulation training.
  Stated by Surrey and Sussex Healthcare NHS TrustStated completed
Respondent positions 10
1. Position
  Limited evidence means fully evidenced national guidelines for rapid sequence induction are unlikely to be produced.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsUnable to act
1. Position
  Updated national guidance for RSI, TIVA and cricoid pressure falls outside the regulatory scope.
  Stated by Care Quality CommissionOutside remit
2. Position
  Updated national RSI anaesthesia guidelines fall outside NHS England’s remit.
  Stated by NHS EnglandOutside remit
3. Position
  The Royal College of Anaesthetists and other named organisations should address updated national RSI anaesthesia guidelines.
  Stated by NHS EnglandRedirects responsibility
4. Position
  The College will not comment on the provision of general anaesthesia in operating theatres.
  Stated by Royal College of Emergency MedicineOutside remit
5. Position
  Medical Royal Colleges and professional bodies are considered best placed to respond on national anaesthesia guidelines.
  Stated by Department of Health and Social CareRedirects responsibility
6. Position
  National guidance supports modified total intravenous anaesthesia during rapid sequence induction, which is accepted practice across the United Kingdom.
  Stated by Surrey and Sussex Healthcare NHS TrustDisputes the concern
7. Position
  Robust evidence neither supports nor refutes cricoid pressure during rapid sequence induction, limiting development of definitive guidance.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsUnable to act
8. Position
  Recipients with anaesthesia expertise are best placed to respond to concerns 6, 7 and 8.
  Stated by Royal College of PhysiciansRedirects responsibility
9. Position
  Cricoid pressure is not universally required during rapid sequence induction because it can make intubation more difficult and is an optional measure.
  Stated by Surrey and Sussex Healthcare NHS TrustDisputes the concern
AI-generated summary

Pamela Anne Marking · 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

Pamela Anne Marking was admitted with abdominal symptoms, was diagnosed with a nosebleed by a Physician Associate and discharged without medical review or direct medical supervision. She later returned with small bowel obstruction caused by an incarcerated femoral hernia and aspirated feculent fluid during induction of anaesthesia for emergency surgery, subsequently dying from respiratory failure and sepsis. The concerns included the Physician Associate’s role, supervision and scope of practice, and the absence of updated guidance for rapid sequence induction, TIVA and airway protection.

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 updated guidelines for rapid sequence induction of anaesthesia in emergency surgery
Wider context from the report
“6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice. ”
Source location
Pamela Anne Marking · Prevention of Future Deaths report
Page 3 · concerns
Open source report
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 updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction
Wider context from the report
“8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved. ”
Source location
Pamela Anne Marking · 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
Share learning from Mrs Marking’s death with members and publish a best-practice statement on RSI.

Verbatim wording from the response
“The most important step to reduce the risks associated with RSI, as recommended by NAP4, is to undertake an individualised risk assessment and act on it. The NAP4 report⁷ states “All patients should have their risk of aspiration assessed and recorded before anaesthesia. The airway management strategy should be consistent with the identified risk of aspiration.” Furthermore, NAP7 report⁸ recommends “Anaesthetists should treat cases of acute abdomen as high risk for aspiration, assess the extent of that risk and plan airway management accordingly. Each airway manager should decide which elements of RSI they wish to use and be prepared to justify their use or omission.” We reinforce our support for these statements and will share the learning from Mrs Marking’s death with our members. As part of this we will publish a best practice statement on RSI.”

Source location
Response from Association of Anaesthetists - RCOA - Difficult Airways Society
Page 2 · response
Published 26 February 2025
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
Use a modified total intravenous anaesthesia technique with predetermined propofol and muscle-relaxant boluses when performing rapid sequence induction with TIVA.

Verbatim wording from the response
“At the Trust, if a clinician is using TIVA for RSI, they always use a modified TIVA technique which involves a predetermined dose of propofol as induction agent as a bolus and a predetermined dose of muscle relaxant as a bolus dose. This allows for rapid anaesthesia, as per the enclosed guideline.”

Source location
Response from Surrey and Sussex NHS
Page 4 · response
Published 26 February 2025
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
Communicate and reinforce the use of cricoid pressure for rapid sequence induction in bowel obstruction through meetings, induction training, and simulation training.

Verbatim wording from the response
“The use of cricoid pressure during RSI is not universal in all situations as it can make intubation more difficult and is listed as an optional measure by the Difficult Airway Society. However, the Trust accepts that in the setting of bowel obstruction, with the increased risk of aspiration, cricoid pressure should have been used. This has been communicated across the whole anaesthetic team at a departmental meeting and in the Mortality & Morbidity meeting. All anaesthetic trainees at their departmental induction are instructed to use cricoid pressure and this is reiterated in regular simulation training.”

Source location
Response from Surrey and Sussex NHS
Page 4 · response
Published 26 February 2025
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
Limited evidence means fully evidenced national guidelines for rapid sequence induction are unlikely to be produced.

Verbatim wording from the response
“It is worth stating from the outset that the topic of rapid sequence induction (RSI) is controversial. By its emergency nature it is difficult to study scientifically and robust evidence supporting or refuting many of its components is simply lacking. Given the challenges of designing studies to provide stronger evidence for or against its use, it is unlikely that fully evidenced guidelines could be produced. Best clinical practice relies in addition to available evidence on careful risk assessment and risk mitigation. In cases where there is high risk of aspiration the potential benefits of RSI increase and thus its use is more rational.”

Source location
Response from Association of Anaesthetists - RCOA - Difficult Airways Society
Page 1 · response
Published 26 February 2025
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
Updated national guidance for RSI, TIVA and cricoid pressure falls outside the regulatory scope.

Verbatim wording from the response
“We are unable to comment on this point due to it being outside of the remit of our regulatory scope.”

Source location
Response from CQC
Page 4 · response
Published 26 February 2025
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
Updated national RSI anaesthesia guidelines fall outside NHS England’s remit.

Verbatim wording from the response
“Your Report also raises concerns around the lack of updated national guidelines relevant to rapid sequence induction (RSI) of anaesthesia, but these issues fall outside of NHS England’s remit and would be best addressed by the Royal College of Anaesthetists and other associated organisations named in your Report. NHS England will give due consideration to their responses to the Coroner.”

Source location
Response from NHSE
Page 1 · response
Published 26 February 2025
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
The Royal College of Anaesthetists and other named organisations should address updated national RSI anaesthesia guidelines.

Verbatim wording from the response
“Your Report also raises concerns around the lack of updated national guidelines relevant to rapid sequence induction (RSI) of anaesthesia, but these issues fall outside of NHS England’s remit and would be best addressed by the Royal College of Anaesthetists and other associated organisations named in your Report. NHS England will give due consideration to their responses to the Coroner.”

Source location
Response from NHSE
Page 1 · response
Published 26 February 2025
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
The College will not comment on the provision of general anaesthesia in operating theatres.

Verbatim wording from the response
“RCEM does not feel it would be appropriate to comment on matters related to the provision of general anaesthesia in the operating theatre.”

Source location
Response from RCEM
Page 2 · response
Published 26 February 2025
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
Medical Royal Colleges and professional bodies are considered best placed to respond on national anaesthesia guidelines.

Verbatim wording from the response
“In preparing this response, the Department notes that the report has been sent to a number of medical Royal Colleges and professional bodies relating to anaesthesia. We think these organisations are best placed to respond to points 6, 7 and 8 of your report which”

Source location
Response from DHSC
Page 1 · response
Published 26 February 2025
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
National guidance supports modified total intravenous anaesthesia during rapid sequence induction, which is accepted practice across the United Kingdom.

Verbatim wording from the response
“Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery: Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice.”

Source location
Response from Surrey and Sussex NHS
Page 3 · response
Published 26 February 2025
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
Robust evidence neither supports nor refutes cricoid pressure during rapid sequence induction, limiting development of definitive guidance.

Verbatim wording from the response
“Your report also raised a concern regarding the “lack of updated guidelines for use of cricoid pressure and other measures to protect the airway during an RSI anaesthetic”. Like other elements of RSI, the use of cricoid force remains a controversial topic, without robust evidence to either support or refute its value⁹. The NAP4 report⁷ recommended “on balance, rapid sequence induction should continue to be taught as a standard technique for protection of the airway. Further focused research might usefully be performed to explore its efficacy, limitations and also explore the consequences of its omission.” It also suggested “to maximise the likelihood of good quality cricoid force being applied, those who perform cricoid force should be trained in its methodology, should practise at regular intervals and should consider the use of simple methods of simulation.””

Source location
Response from Association of Anaesthetists - RCOA - Difficult Airways Society
Page 2 · response
Published 26 February 2025
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
Recipients with anaesthesia expertise are best placed to respond to concerns 6, 7 and 8.

Verbatim wording from the response
“This letter has also been addressed to recipients with expertise in anaesthesia, who may be best placed to respond to concerns 6, 7 and 8.”

Source location
Response from Royal College of Physicians
Page 1 · response
Published 26 February 2025
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
Cricoid pressure is not universally required during rapid sequence induction because it can make intubation more difficult and is an optional measure.

Verbatim wording from the response
“Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic: Evidence was heard that as cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.”

Source location
Response from Surrey and Sussex NHS
Page 4 · response
Published 26 February 2025
Open published response
11 Jan2018
Stoke-on-Trent and North Staffordshire
Concerns raised1
1. Failure to apply cricoid pressure when clinically indicated
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.
Respondent positions 2
1. Position
  Evidence does not support routine cricoid pressure and indicates it may hinder airway management or increase risks in some circumstances.
  Stated by University Hospital of North Midlands NHS Trust (UHNMDisputes the concern
1. Position
  Whether to use cricoid pressure is determined by the treating anaesthetist according to individual airway and aspiration risks.
  Stated by University Hospital of North Midlands NHS Trust (UHNMRedirects responsibility
AI-generated summary

Donald John TILL · 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

Donald John TILL, a 68-year-old man with a history of small bowel adenocarcinoma, presented with abdominal pain and vomiting caused by a large bowel obstruction. After emergency surgery on 4 January 2017, he aspirated faeculent material during anaesthesia, developed aspiration pneumonia, deteriorated in intensive care, and died on 5 January 2017. Concerns included unavailable previous medical records, anaesthesia on a ward bed without rapid tilt, problems sourcing suitable bronchoscopy equipment, and the non-use of cricoid pressure and a nasogastric tube before anaesthesia.

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 apply cricoid pressure when clinically indicated
Wider context from the report
“4. Cricoid pressure and NG tubes were not used in this case. ”
Source location
Donald John TILL · 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
Evidence does not support routine cricoid pressure and indicates it may hinder airway management or increase risks in some circumstances.

Verbatim wording from the response
“a. Cricoid pressure - it was heard at the inquest that several published reviews of the research regarding cricoid pressure concluded that there is little evidence to support the widespread belief that it reduces the incidence of gastric aspiration. There is evidence to suggest that the use of cricoid pressure impedes the management of the airway both making mask ventilation more difficult and also laryngoscopy and intubation. There is also evidence that the application of cricoid pressure relaxes the lower oesophageal sphincter potentially making regurgitation and aspiration more likely.”

Source location
2018-0013-Response-by-University-Hospitals-of-North-Midlands
Page 3 · response
Published 7 March 2018
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
Whether to use cricoid pressure is determined by the treating anaesthetist according to individual airway and aspiration risks.

Verbatim wording from the response
“The decision to use cricoid pressure should therefore be based upon an assessment of the patient’s airway together with the risk factors for those difficult airway management situations. This should be considered together with the risk of aspiration against the evidence that repeated attempts at intubation, are associated with rapidly increasing risk of aspiration and that if a patient should vomit with cricoid pressure applied oesophageal rupture (leading to mediastinitis with a mortality of 13-100%) can occur.”

Source location
2018-0013-Response-by-University-Hospitals-of-North-Midlands
Page 3 · response
Published 7 March 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery

Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction

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.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.10

Concerns raised1

Failure to apply cricoid pressure when clinically indicated

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 3

Respondent positions 10

Respondent positions 2