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
Distinct published reports
Individual concerns
3
A report can raise multiple concerns
Date range
2018–2025
First to latest report issue date
Stated actions
3
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.
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
NHS trust2
Executive non-departmental public body1
Health and care professional regulator1
Health and social care service regulator1
Healthcare site1
Health professional body1
Ministerial department1
Registered charity1
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.
Surrey
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
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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 plannedThe respondent said that this action was planned when they made their response on 26 February 2025.
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 unclearThe respondent did not make the status of this action clear when they made their response on 26 February 2025.
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 completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.10
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 actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Updated national guidance for RSI, TIVA and cricoid pressure falls outside the regulatory scope.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
Updated national RSI anaesthesia guidelines fall outside NHS England’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Royal College of Anaesthetists and other named organisations should address updated national RSI anaesthesia guidelines.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The College will not comment on the provision of general anaesthesia in operating theatres.
Stated by Royal College of Emergency MedicineOutside remitThe respondent said that this matter was outside its role or authority.
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 responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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 concernThe respondent disagreed with part of the concern or the basis for it.
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 actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Recipients with anaesthesia expertise are best placed to respond to concerns 6, 7 and 8.
Stated by Royal College of PhysiciansRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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 concernThe respondent disagreed with part of the concern or the basis for it.
Stoke-on-Trent and North Staffordshire
Concerns raised1
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 A position is what a respondent says about the concern when they do not describe a specific action.2
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 concernThe respondent disagreed with part of the concern or the basis for it.
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 responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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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.
