Recurring concern

Unreliable capnography use during intubation and resuscitation

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First reported 17 Nov 2017•Latest report 13 Jun 2024

Definition

What this concern includes

Includes failures of the capnography safety process during intubation or resuscitation, including dissemination and understanding of relevant guidance, availability, correct use, and assurance that clinical staff who may intubate use capnography appropriately.

Not included

Excludes generic clinical training, guidance dissemination or monitoring deficiencies without a direct capnography connection.
Excludes failures involving airway management, intubation or resuscitation where capnography is not the deficient control.
Excludes failures occurring after capnography has been reliably used, including unrelated treatment or escalation failures.
Excludes capnography concerns outside intubation or resuscitation unless they explicitly support the same bounded capnography safety process.

Reports: 4
Individual concerns: 6
Date range: 2017–2024
Stated actions: 12

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.

Royal College of Anaesthetists3

Department of Health and Social Care2

NHS England2

Difficult Airway Society1

Faculty of Intensive Care Medicine1

Milton Keynes University Hospital1

North Cumbria Integrated Care NHS Foundation Trust1

North West Anglia NHS Foundation Trust1

Royal College of Emergency Medicine1

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.

13 Jun2024
Avon
Concerns raised1
1. Failure to endorse and disseminate PUMA airway management guidance
This report raised 1 other concern. 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 1
1. Action
  Disseminate key PUMA guideline messages to members through safety communications and events.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Faculty of Intensive Care Medicine and Royal College of AnaesthetistsStated planned
Respondent positions 2
1. Position
  Some concerns about PUMA guideline endorsement and dissemination fall outside NHS England’s national policy or programme remit.
  Stated by NHS EnglandOutside remit
1. Position
  The Royal Colleges are better placed to respond to concerns outside NHS England’s national policy or programme remit.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Joseph Lawrence Parker · 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

Joseph Lawrence Parker took an overdose of medication on 17 February 2022, collapsed, and was taken to Southmead Hospital for intubation. The breathing tube was accidentally positioned in the oesophagus and the misplacement was not identified promptly, contributing to cardiac arrest, hypoxic encephalopathy, and his death on 16 April 2022. The principal concerns relate to recognising incorrect tube placement, the use and interpretation of capnography, and the dissemination of relevant airway-management guidance.

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 endorse and disseminate PUMA airway management guidance
Wider context from the report
“(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 state, 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. ”
Source location
Joseph Lawrence Parker · 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
Disseminate key PUMA guideline messages to members through safety communications and events.

Verbatim wording from the response
“This reflects the fact that in some cases of oesophageal intubation the capnograph trace has not been flat, but instead attenuated and abnormal. Our organisations are all supportive of the PUMA guidelines and plan to disseminate the key messages to our members through our safety communications and events. SALG publishes regular Patient Safety Updates, which are distributed to all members of the Association of Anaesthetists and Royal College of Anaesthetists. FICM publishes regular Safety Bulletins, which are distributed to all their members.”

Source location
Response from Association of Anaesthetists, RCOA and Faculty of Intensive Care Medicine - Joint Response
Page 1 · response
Published 31 July 2024
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
Some concerns about PUMA guideline endorsement and dissemination fall outside NHS England’s national policy or programme remit.

Verbatim wording from the response
“My response focuses on those areas of concern that fall under the remit of NHS England’s national policy or programmes. NHS England notes that you have also sent your Report to the Royal College of Anaesthetists (RCoA), Faculty of Intensive Care Medicine (FICM), and the Royal College of Emergency Medicine (RCEM), who are better placed to respond to your matters of concern. NHS England will carefully consider their responses to the Coroner in due course.”

Source location
Response from NHS England
Page 1 · response
Published 31 July 2024
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 Colleges are better placed to respond to concerns outside NHS England’s national policy or programme remit.

Verbatim wording from the response
“My response focuses on those areas of concern that fall under the remit of NHS England’s national policy or programmes. NHS England notes that you have also sent your Report to the Royal College of Anaesthetists (RCoA), Faculty of Intensive Care Medicine (FICM), and the Royal College of Emergency Medicine (RCEM), who are better placed to respond to your matters of concern. NHS England will carefully consider their responses to the Coroner in due course.”

Source location
Response from NHS England
Page 1 · response
Published 31 July 2024
Open published response
6 Sep2021
Milton Keynes
Concerns raised1
1. Lack of awareness of the capnography safety campaign among anaesthesia staff
This report raised 6 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 6
1. Action
  Disseminate key lessons through Royal College, Association and Difficult Airway Society journals, newsletters and social media.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated planned
2. Action
  Present key lessons at specified anaesthesia, airway and perioperative educational conferences and meetings.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated planned
3. Action
  Work with operating department and perioperative stakeholders to ensure key messages reach the whole theatre team.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated planned
1. Action
  Work with other Royal Colleges to share key messages with all medical professionals undertaking intubation.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated planned
2. Action
  Publish and promote the “Capnography in Cardiac Arrest: No Trace = Wrong Place” video through professional communication channels.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated completed
3. Action
  Continue disseminating key lessons on preventing unrecognised oesophageal intubation through webpages, talks, publications, online resources and social media.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated in progress
AI-generated summary

Glenda May Logsdail · 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

Glenda May Logsdail was admitted with acute appendicitis and underwent emergency surgery. During induction of anaesthesia, an endotracheal tube was misplaced in the oesophagus and this was not recognised for a prolonged period, resulting in hypoxia, cardiac arrest, irreversible brain damage and her death. Concerns included failures to confirm tube placement, fixation on an incorrect diagnosis, inadequate team leadership and communication during the emergency, and inconsistent ventilator display configurations.

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 awareness of the capnography safety campaign among anaesthesia staff
Wider context from the report
“(1) I was concerned to find that the anaesthetising Consultant Anaesthetist was not aware of the Royal College of Anaesthetists campaign video “Capnography in Cardiac Arrest: No Trace = Wrong Place”. (2) I became even more concerned when towards the end of the Inquest when I was hearing evidence on the Incident Investigation Report the author, told me he had not been aware of the campaign himself until this incident. ”
Source location
Glenda May Logsdail · 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
Disseminate key lessons through Royal College, Association and Difficult Airway Society journals, newsletters and social media.

Verbatim wording from the response
“It is disappointing that both the anaesthetist involved in the case and the author of the incident investigation report were not aware of the “Capnography in Cardiac Arrest: No Trace = Wrong Place” video. This was published in 2018 and was widely promoted through the RCoA’s, the Association’s and DAS’s communication channels. We recognise that much of this promotional activity was concentrated in a relatively short period of time. We plan for the following coordinated actions to take place over the next year. We will:”

Source location
2021-0295-Response-from-Royal-College-of-Anaesthetists_Published
Page 2 · response
Published 9 September 2021
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
Present key lessons at specified anaesthesia, airway and perioperative educational conferences and meetings.

Verbatim wording from the response
“It is disappointing that both the anaesthetist involved in the case and the author of the incident investigation report were not aware of the “Capnography in Cardiac Arrest: No Trace = Wrong Place” video. This was published in 2018 and was widely promoted through the RCoA’s, the Association’s and DAS’s communication channels. We recognise that much of this promotional activity was concentrated in a relatively short period of time. We plan for the following coordinated actions to take place over the next year. We will:”

Source location
2021-0295-Response-from-Royal-College-of-Anaesthetists_Published
Page 2 · response
Published 9 September 2021
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
Work with operating department and perioperative stakeholders to ensure key messages reach the whole theatre team.

Verbatim wording from the response
“It is disappointing that both the anaesthetist involved in the case and the author of the incident investigation report were not aware of the “Capnography in Cardiac Arrest: No Trace = Wrong Place” video. This was published in 2018 and was widely promoted through the RCoA’s, the Association’s and DAS’s communication channels. We recognise that much of this promotional activity was concentrated in a relatively short period of time. We plan for the following coordinated actions to take place over the next year. We will:”

Source location
2021-0295-Response-from-Royal-College-of-Anaesthetists_Published
Page 2 · response
Published 9 September 2021
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
Work with other Royal Colleges to share key messages with all medical professionals undertaking intubation.

Verbatim wording from the response
“It is disappointing that both the anaesthetist involved in the case and the author of the incident investigation report were not aware of the “Capnography in Cardiac Arrest: No Trace = Wrong Place” video. This was published in 2018 and was widely promoted through the RCoA’s, the Association’s and DAS’s communication channels. We recognise that much of this promotional activity was concentrated in a relatively short period of time. We plan for the following coordinated actions to take place over the next year. We will:”

Source location
2021-0295-Response-from-Royal-College-of-Anaesthetists_Published
Page 2 · response
Published 9 September 2021
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 promote the “Capnography in Cardiac Arrest: No Trace = Wrong Place” video through professional communication channels.

Verbatim wording from the response
“It is disappointing that both the anaesthetist involved in the case and the author of the incident investigation report were not aware of the “Capnography in Cardiac Arrest: No Trace = Wrong Place” video. This was published in 2018 and was widely promoted through the RCoA’s, the Association’s and DAS’s communication channels. We recognise that much of this promotional activity was concentrated in a relatively short period of time. We plan for the following coordinated actions to take place over the next year. We will:”

Source location
2021-0295-Response-from-Royal-College-of-Anaesthetists_Published
Page 2 · response
Published 9 September 2021
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
Continue disseminating key lessons on preventing unrecognised oesophageal intubation through webpages, talks, publications, online resources and social media.

Verbatim wording from the response
“We launched a coordinated campaign to disseminate the key learning points from Mrs Logsdail’s case to our specialty. This included the following actions:”

Source location
2021-0295 - Response from Royal College of Anaesthetists
Page 1 · response
Published 9 September 2021
Open published response
25 Jan2018
Cumbria
Concerns raised1
1. Lack of understanding of capnography interpretation during CPR
This report raised 3 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

Sharon Rose Grierson · 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

Sharon Rose Grierson, aged 44, underwent elective surgery to remove a benign vocal cord polyp and developed laryngospasm during extubation. Endotracheal tubes were twice placed in the oesophagus rather than the trachea, leading to oxygen deprivation, hypoxic brain injury and her death. Concerns included failure to appreciate capnography readings, lack of coordination and situational awareness, and limited experience of senior staff in crisis situations.

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 understanding of capnography interpretation during CPR
Wider context from the report
“(1) There was a lack of appreciation of what the capnography was indicating and some lack of understanding of the trace one might expect to see during CPR. ”
Source location
Sharon Rose Grierson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Nov2017
Cambridgeshire and Peterborough
Concerns raised3
1. Failure to ensure sufficient understanding of capnography among clinical staff who may intubate patients
2. Failure to ensure utilisation of capnography by clinical staff who may intubate patients
3. Failure to observe capnography for up to 15 to 20 seconds after intubation
This report raised 1 other concern. 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 5
1. Action
  Deliver high-fidelity airway simulation training covering capnography, technical airway skills, human factors and crisis-management skills to all Hinchingbrooke anaesthetic staff.
  Stated by North West Anglia NHS Foundation TrustStated in progress
2. Action
  Publish and circulate safety information on exhaled carbon dioxide during resuscitation through anaesthesia newsletters and Patient Safety Update.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated planned
3. Action
  Present the exhaled-carbon-dioxide issue to national Airway Leads and invite feedback on improving training.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated planned
1. Action
  Ask e-Learning for Anaesthesia providers to consider highlighting exhaled carbon dioxide in intubation, capnography and resuscitation sessions.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated planned
2. Action
  Work with the AAGBI to promote regular multidisciplinary crisis simulation through its forthcoming emergency-management handbook.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated in progress
AI-generated summary

Peter Saint · 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

Peter Saint was admitted for routine elective knee replacement surgery and died after an endotracheal tube was placed in his oesophagus, resulting in approximately 38 minutes without effective lung ventilation and subsequent hypoxic brain damage. The principal concerns were inadequate understanding and interpretation of capnography, failure to follow the required confirmation procedure after intubation, and insufficient ongoing training for anaesthetists in crisis situations.

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 ensure sufficient understanding of capnography among clinical staff who may intubate patients
Wider context from the report
“I am concerned that the evidence in this case, including the expert evidence, established that notwithstanding the findings and recommendations of the 2011 NAP4 there is a continuing failure to ensure that capnography is sufficiently understood and utilised by all clinical staff who may intubate patients. ”
Source location
Peter Saint · Prevention of Future Deaths report
Page 2 · 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
Failure to ensure utilisation of capnography by clinical staff who may intubate patients
Wider context from the report
“I am concerned that the evidence in this case, including the expert evidence, established that notwithstanding the findings and recommendations of the 2011 NAP4 there is a continuing failure to ensure that capnography is sufficiently understood and utilised by all clinical staff who may intubate patients. ”
Source location
Peter Saint · Prevention of Future Deaths report
Page 2 · 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
Failure to observe capnography for up to 15 to 20 seconds after intubation
Wider context from the report
“The evidence heard, including the expert evidence, confirmed that an integral part of the process of intubating a patient requires that the anaesthetist, following the placement of the intubation tube into the patient, observes the capnography for a period of up to 15 to 20 seconds to ensure that a “proper CO2 end tidal wave” can be detected; failure to do so would be a “fundamental and basic error” and a “serious error”. I am concerned that this procedure was not followed by either the lead consultant anaesthetist in this case or the anaesthetists who attended to assist him. The expert evidence indicated a lack of widespread, regular, mandatory on-going training for anaesthetists in drills dealing with crisis situations potentially facing an anaesthetic team particularly in relation to the issues of “task fixation” and “confirmatory bias”, and that such training would be beneficial. ”
Source location
Peter Saint · 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
Deliver high-fidelity airway simulation training covering capnography, technical airway skills, human factors and crisis-management skills to all Hinchingbrooke anaesthetic staff.

Verbatim wording from the response
“All members of the anaesthetic department at Hinchingbrooke are to participate in an airway simulation course at a high fidelity simulation centre. We have identified a suitable course and are in the process of planning training with the course provider. It is a one day course for anaesthetist-DOP teams that combines human factors with airway technical skills. It includes interactive team training, simulation, error avoidance strategy, airway-technical skills, human factors in crisis management and practical briefing/debriefing skills. Due to the logistics of having all of the anaesthetists attending external training, while continuing to staff the service for patients it will be necessary to run the course on multiple dates. This course will address the specific issues regarding the use and interpretation of capnography that were raised in your letter.”

Source location
2017-0404-Response-by-North-West-Anglia-NHS-Trust
Page 1 · response
Published 15 February 2018
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 circulate safety information on exhaled carbon dioxide during resuscitation through anaesthesia newsletters and Patient Safety Update.

Verbatim wording from the response
“We are concerned that despite the emphasis placed upon the continuing presence of exhaled carbon dioxide during resuscitation from cardiac arrest in resources such as NAP4 and the Advanced Life Support programme run by the Resuscitation Council UK, there are still clinicians holding senior positions in anaesthesia in the NHS who are unaware of this important fact. We will seek to address this issue by:”

Source location
2017-0404-Response-by-RCOA
Page 1 · response
Published 15 February 2018
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
Present the exhaled-carbon-dioxide issue to national Airway Leads and invite feedback on improving training.

Verbatim wording from the response
“We are concerned that despite the emphasis placed upon the continuing presence of exhaled carbon dioxide during resuscitation from cardiac arrest in resources such as NAP4 and the Advanced Life Support programme run by the Resuscitation Council UK, there are still clinicians holding senior positions in anaesthesia in the NHS who are unaware of this important fact. We will seek to address this issue by:”

Source location
2017-0404-Response-by-RCOA
Page 1 · response
Published 15 February 2018
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
Ask e-Learning for Anaesthesia providers to consider highlighting exhaled carbon dioxide in intubation, capnography and resuscitation sessions.

Verbatim wording from the response
“• Asking those charged with providing the RCoA’s comprehensive online educational programme (e-Learning for Anaesthesia) to consider highlighting this issue in sessions on intubation, capnography and resuscitation.”

Source location
2017-0404-Response-by-RCOA
Page 1 · response
Published 15 February 2018
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
Work with the AAGBI to promote regular multidisciplinary crisis simulation through its forthcoming emergency-management handbook.

Verbatim wording from the response
“• Working with the AAGBI to promote regular multidisciplinary crisis simulation when it publishes its forthcoming Quick Reference Handbook, a series of national guidance documents on the management of emergency situations in anaesthetic practice. This handbook emphasises the importance of multidisciplinary crisis practice and the significance of the absence of ETCO2 in cardiac arrest.”

Source location
2017-0404-Response-by-RCOA
Page 2 · response
Published 15 February 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to endorse and disseminate PUMA airway management guidance

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.1

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

Concerns raised1

Lack of awareness of the capnography safety campaign among anaesthesia staff

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.6

Concerns raised1

Lack of understanding of capnography interpretation during CPR

Concerns raised3

Failure to ensure sufficient understanding of capnography among clinical staff who may intubate patients

Failure to ensure utilisation of capnography by clinical staff who may intubate patients

Failure to observe capnography for up to 15 to 20 seconds after intubation

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.5

Actions described in response 1

Respondent positions 2

Actions described in response 6

Actions described in response 5