ENT UK

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First report 10 Dec 2015•Latest report 10 Dec 2015

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
4

Described in responses

Concerns and recipient responses

Statements from ENT UK linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. London Inner (South)

    AI-generated summary

    Ololade Olaobaju · 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

    Ololade Olaobaju was treated for progressive respiratory failure following community-acquired pneumonia and was transferred to intensive care for mechanical ventilation. After unsuccessful attempts at intubation, needle cricothyroidotomy and “Quicktrack”, she suffered a cardiac arrest during an attempted surgical tracheostomy and could not be resuscitated. The report identified a concern that existing guidance did not cover the preferred front-of-neck access when anaesthetists and ENT surgeons were both present, particularly in a rapidly deteriorating “Can’t Intubate Can’t Oxygenate” situation.

    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. The report was sent to ENT UK; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of joint guidance for front-of-neck access during a “Can’t Intubate Can’t Oxygenate” emergency involving anaesthetists and ENT surgeons

    Wider context from the report

    “(1) For the purposes of the inquest I received an expert report from Dr Andrew Hartle. Reference was also made to the Difficult Airway Society Guidelines 2004 and 2015. The DAS guidelines suggest that, for an anaesthetist, an appropriate progression would be to undertake surgical (scalpel) cricothyroidotomy after unsuccessful cannula cricothyroidotomy. In this case, an ENT surgeon (clinical fellow grade) arrived and took over before scalpel cricothyroidotomy was attempted. The ENT surgeon decided to attempt tracheostomy rather than scalpel cricothyroidotomy. The benefit of tracheostomy is that it would have provided a more permanent airway. The evidence was that this is an unusual situation and that the experience of all the witnesses was therefore limited in performing emergency cricothyroidotomy and emergency tracheostomy. I concluded that the decision as to whether to opt for tracheostomy or scalpel cricothyroidotomy was a clinical judgment made in the light of the circumstances at the time. However, this was rapidly deteriorating situation and the ENT surgeon accepted that scalpel cricothyroidotomy may have been a simpler procedure. This became a “Can’t Intubate Can’t Oxygenate” situation in which both anaesthetists and ENT surgeons were present. My understanding is that the DAS guidelines are provided for anaesthetists. Different considerations may apply to ENT surgeons. The question as to the preferred mode of front of neck access in this situation therefore appears not to be covered by the existing guidelines. Individual practitioners faced with such a situation are likely to have limited experience. My understanding is that there is currently no joint guidance to cover this type of situation when both anaesthetists and ENT surgeons are present. ”
    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

    Raise surgeons’ awareness of appropriate emergency airway techniques through journal editorials, curriculum advocacy and emphasis on a standard surgical approach.

    Verbatim wording from the response

    “• We will take actions to raise awareness amongst surgeons of the issues discussed, and particularly the best choice of surgical technique. We will do this by:- o Submitting an editorial to the key ENT journals (Clinical Otolaryngology and The British Journal of Oral and Maxillofacial Surgery (BJOAMS)), as well as the British Journal of Anaesthesia. o Contacting the President of the Royal College of Surgeons asking for the surgical management of an airway crisis to be incorporated into the training curriculum for surgeons-in-training. o We will emphasise to surgeons the need for a standard surgical approach in these cases.”

    Source location

    Ololade-Olabaju-Response
    Page 3 · response
    Published 15 December 2015

    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 DAS and AAGBI to support anaesthetists in achieving and maintaining competence in surgical cricothyroidotomy through professional development and curriculum development.

    Verbatim wording from the response

    “• We will work together (DAS, RCoA, AAGBI) to help anaesthetists of all grades (trainee, Consultant, SAS) to achieve and maintain competence in performing surgical cricothyroidotomies. This will be achieved by:- o Encouraging personal development activities and Continuing Professional Development o Developing the curriculum for anaesthetists-in-training.”

    Source location

    Ololade-Olabaju-Response
    Page 3 · response
    Published 15 December 2015

    Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026