Recurring concern

Unsafe endotracheal tube management

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First reported 3 Feb 2017•Latest report 6 Sep 2021

Definition

What this concern includes

Includes failures of controls specifically dedicated to safe endotracheal tube management, including placement confirmation, ongoing assessment, recognition of blockage or displacement, timely escalation and replacement.

Not included

Excludes failures concerning nasogastric or tracheostomy tubes unless the report explicitly concerns endotracheal tube management.
Excludes generic airway, resuscitation, staffing, training or communication deficiencies unless they directly impair a dedicated endotracheal tube control.
Excludes clinical deterioration or respiratory treatment failures where no endotracheal tube management deficiency is identified.

Reports: 3
Individual concerns: 3
Date range: 2017–2021
Stated actions: 13

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 Anaesthetists2

Care Quality Commission1

Department of Health and Social Care1

Difficult Airway Society1

Fisher & Paykel Healthcare Limited1

HCA Healthcare UK1

London Bridge Hospital1

Milton Keynes University Hospital1

NHS England1

North West Anglia NHS Foundation Trust1

Nursing and Midwifery Council1

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.

6 Sep2021
Milton Keynes
Concerns raised1
1. Failure to perform confirmatory checks of endotracheal tube placement
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 4
1. Action
  Develop multidisciplinary training resources and short scenarios on unrecognised oesophageal intubation.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated planned
2. 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
3. Action
  Develop and disseminate multidisciplinary team training resources on oesophageal intubation, including flashcards and short scenarios.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated completed
1. Action
  Maintain work to prevent unrecognised oesophageal intubation through the Safe Anaesthesia Liaison Group.
  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
Failure to perform confirmatory checks of endotracheal tube placement
Wider context from the report
“(3) As Mrs Logsdail’s condition deteriorated there was no evidence that any confirmatory checks, notably looking for the presence of a capnography trace or expiratory misting, were done to check correct placement of the endo tracheal tube. ”
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
Develop multidisciplinary training resources and short scenarios on unrecognised oesophageal intubation.

Verbatim wording from the response
“Your report highlights the critical importance of human factors in safe anaesthetic practice. Multidisciplinary team training has an important role to play in rehearsing emergency drills, embedding non-technical skills in practice and allowing teams to learn how to function well as a whole within a flattened hierarchy. Regular, multidisciplinary team training is one of the standards for our Anaesthesia Clinical Services Accreditation (ACSA) scheme. However, in practice, it is a standard that many departments find difficult to meet to an adequate level due to the pressure on theatre time. To support this, we will:”

Source location
2021-0295-Response-from-Royal-College-of-Anaesthetists_Published
Page 1 · 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
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 and disseminate multidisciplinary team training resources on oesophageal intubation, including flashcards and short scenarios.

Verbatim wording from the response
“To help embed the key messages of the campaign into practice, and recognising the critical importance of human factors in safe anaesthetic practice, we developed resources for multidisciplinary team training on the subject of oesophageal intubation. One of these resources were a set of flashcards, short scenarios that could be delivered with no need for theatre downtime. The flashcards have been downloaded over 2,000 times. Colleagues at the Royal United Hospital Bath developed a packaged of “tea trolley” training on the subject of oesophageal intubation, which has also been made freely available on our webpage.”

Source location
2021-0295 - Response from Royal College of Anaesthetists
Page 1 · 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
Maintain work to prevent unrecognised oesophageal intubation through the Safe Anaesthesia Liaison Group.

Verbatim wording from the response
“• We will maintain our work to prevent unrecognised oesophageal intubation through the Safe Anaesthesia Liaison Group, which is a collaborative project between the Association of Anaesthetists, the Royal College of Anaesthetists and NHS England.”

Source location
2021-0295 - Response from Royal College of Anaesthetists
Page 2 · response
Published 9 September 2021
Open published response
17 Nov2017
Cambridgeshire and Peterborough
Concerns raised1
1. Failure to observe capnography for up to 15 to 20 seconds after intubation
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.
Actions described in response 1
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
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 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
3 Feb2017
London Inner (South)
Concerns raised1
1. Delays in identifying and replacing blocked endotracheal tubes
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.
Actions described in response 8
1. Action
  Require continuous capnography for all ventilator-dependent critically ill patients and extend emergency availability with portable monitors.
  Stated by HCA Healthcare UK and London Bridge HospitalStated completed
2. Action
  Train ICU clinical staff to interpret capnography through induction courses, competency materials and recurring Learning Academy training.
  Stated by HCA Healthcare UK and London Bridge HospitalStated completed
3. Action
  Implement DOPES airway assessment and embed it in cardiac arrest training and the Cardiac Arrest Record Checklist.
  Stated by HCA Healthcare UK and London Bridge HospitalStated completed
1. Action
  Deliver ongoing advanced airway, simulation, mock-arrest and blocked-tube training for intensive care staff.
  Stated by HCA Healthcare UK and London Bridge HospitalStated in progress
2. Action
  Review critical care courses and introduce capnography, SBAR and DOPES where previously absent.
  Stated by HCA Healthcare UK and London Bridge HospitalStated completed
3. Action
  Revise the Cardiac Arrest Record Checklist to prompt capnography and DOPES.
  Stated by HCA Healthcare UK and London Bridge HospitalStated completed
4. Action
  Use the Cardiac Arrest Record Checklist during arrests and audit and review post-arrest debrief records.
  Stated by HCA Healthcare UK and London Bridge HospitalStated completed
5. Action
  Investigate the nursing-care concerns in accordance with statutory functions.
  Stated by Nursing and Midwifery CouncilStated in progress
Respondent positions 2
1. Position
  Action on concern 1 is assigned to the NMC; LBH considers itself not required to act because it is not responsible.
  Stated by HCA Healthcare UK and London Bridge HospitalRedirects responsibility
1. Position
  The completed RCA action plan was considered sufficient to mitigate recurrence risk, with the planned actions carried out.
  Stated by Care Quality CommissionExisting arrangements considered sufficient
AI-generated summary

ROBERT ENTENMAN · 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

Robert Entenman was an intubated intensive care patient whose humidifier was turned off from around 12.00pm on 22 May 2015 until 6.00am on 23 May 2015. A mucus plug blocked his endotracheal tube, leading to cardiac arrest shortly after 6.00am; he died on 30 May 2015. Concerns included failures to observe that the humidifier was off, the absence of an alarm on the humidifier, delays in identifying and replacing the blocked tube, and possible delays in communicating suction difficulties to doctors.

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
Delays in identifying and replacing blocked endotracheal tubes
Wider context from the report
“(3) There were delays in identifying that the endotracheal tube had become blocked between 5.32 and 6.00am on 23 May 2015, and thus replacing it earlier. There may have been further such delays after 6.00 am. There may have been a delay by the nursing staff in providing information about difficulties with the suction catheter to the doctors who arrived after the cardiac arrest call was put out. ”
Source location
ROBERT ENTENMAN · 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
Require continuous capnography for all ventilator-dependent critically ill patients and extend emergency availability with portable monitors.

Verbatim wording from the response
“The following steps have been implemented in relation to equipment, training and human factors relevant to the Coroner’s concerns:”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 3 · response
Published 19 February 2017
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
Train ICU clinical staff to interpret capnography through induction courses, competency materials and recurring Learning Academy training.

Verbatim wording from the response
“b. Clinical staff working in ICU receive training in the interpretation of capnography (prior to commencing work in ICU) via courses (critical care, in-prep, and foundation) and via competency booklets. It is thereafter reinforced through a regular programme of training, implemented through the HCA Learning Academy (see A.2.2.b below).”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 3 · response
Published 19 February 2017
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
Implement DOPES airway assessment and embed it in cardiac arrest training and the Cardiac Arrest Record Checklist.

Verbatim wording from the response
“e. LBH has also implemented DOPES (see B.4 below), a system of assessment and diagnosis to be followed by staff in a situation where a suspected “difficult airway” problem arises. DOPES has also been added to the Cardiac Arrest Record Checklist as a prompt for the cardiac arrest team’s scribe.”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 3 · response
Published 19 February 2017
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
Deliver ongoing advanced airway, simulation, mock-arrest and blocked-tube training for intensive care staff.

Verbatim wording from the response
“f. HCA and the Simulation and Interactive Learning (“SaIL”) Centre at Guy’s and St Thomas’ Foundation Trust have collaborated to deliver additional Intensive Care Airway training for intensive care staff (medical and nursing) working within LBH intensive care environments. This is an ongoing programme of training.”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 4 · response
Published 19 February 2017
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
Review critical care courses and introduce capnography, SBAR and DOPES where previously absent.

Verbatim wording from the response
“k. All the critical care courses offered by HCA (usually via a leading London university) have been reviewed and the roles of capnography, SBAR and DOPES introduced where they did not exist previously (see B.4 below).”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 4 · response
Published 19 February 2017
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
Revise the Cardiac Arrest Record Checklist to prompt capnography and DOPES.

Verbatim wording from the response
“c. The Cardiac Arrest Record Checklist has been revised to include prompts for capnography and DOPES (see B.3 below).”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 4 · response
Published 19 February 2017
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 the Cardiac Arrest Record Checklist during arrests and audit and review post-arrest debrief records.

Verbatim wording from the response
“a. The Cardiac Arrest Record Checklist is completed by the scribe (this is generally the Duty Manager) who will prompt the cardiac arrest team on capnography, SBAR and DOPES if necessary during the arrest.”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 6 · response
Published 19 February 2017
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
Investigate the nursing-care concerns in accordance with statutory functions.

Verbatim wording from the response
“We are aware of the particular issues raised about the registered nurse who reviewed Mr Entenman in the time leading up to his death. We are currently investigating this matter and are considering the concerns in accordance with our statutory functions.”

Source location
2017-0011-Response-by-NMC
Page 1 · response
Published 19 February 2017
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
Action on concern 1 is assigned to the NMC; LBH considers itself not required to act because it is not responsible.

Verbatim wording from the response
“Concern numbered (1) indicates that the Nursing and Midwifery Council (“NMC”) has the power to take action. LBH is not required to take action having already satisfied the Coroner that it is not responsible for addressing this concern.”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 2 · response
Published 19 February 2017
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 completed RCA action plan was considered sufficient to mitigate recurrence risk, with the planned actions carried out.

Verbatim wording from the response
“The CQC requested a final copy of the RCA document as part of the inspection process in 2016, and received this on 28 October 2016. The document had been completed on 30 October 2015. It set out the background to the incident, the possible causes and a proposed action plan to prevent the re-occurrence of similar incidents. The CQC was satisfied that the actions set out in the RCA would be sufficient to mitigate the risk of re-occurrence and, further, that those actions had been carried out.”

Source location
2017-0011-Response-by-Care-Quality-Commission
Page 2 · response
Published 19 February 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to perform confirmatory checks of endotracheal tube placement

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.4

Concerns raised1

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.1

Concerns raised1

Delays in identifying and replacing blocked endotracheal tubes

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.8

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 4

Actions described in response 1

Actions described in response 8

Respondent positions 2