Sharon Rose Grierson · Prevention of Future Deaths report

On 15/12/2016 I commenced an investigation into the death of Sharon Rose Grierson. The investigation concluded at the end of the inquest 23rd January 2018. The conclusion of the inquest was On 11th November 2016 the deceased underwent elective surgery at the Cumberland Infirmary Carlisle to remove a polyp from her vocal cords under general anaesthetic. The procedure was uneventful. It was decided to extubate her whilst still under the effect of anaesthetic, in the process of which she went into laryngospasm. Muscle relaxant was administered and she was re-intubated, it was believed, via the trachea. Shortly afterwards she had a cardiac arrest. Assistance had already arrived. Capnography readings showed the absence of exhaled carbon dioxide. In the process of introducing an oro-gastric tube the endotracheal tube, which was found to be in the oesophagus was removed and replaced. The capnograph continued to show abnormal readings, notwithstanding effective and continuous cardio-pulmonary resuscitation. The position of the tube was checked by bronchoscope and was, again, found to be in the oesophagus. It was re-sited. Clinicians had not appreciated that there had, twice, been oesophageal intubation despite the capnography readings. She died on 14th November 2016 as a consequence.

Cause of death:
1a) Global Ischaemic/Hypoxic Brain Injury
1b) Unrecognised Oesophageal Intubation following Extubation after operation to remove Benign Vocal Cord Polyp.

Conclusion:

Died following surgery as a result of being deprived of oxygen due to endotracheal tubes being incorrectly placed on two consecutive occasions.

A 44 year old female who attended CIC for short routine elective laryngoscopy for a small lesion on her larynx.
During the process the patient needed to be intubated. After the procedure she went into laryngospasm and subsequently endotracheal tubes were inserted into her oesophagus twice instead of her trachea.

This led to hypoxic brain injury.
During the course of the incident which lasted about one hour the deceased was attended by four consultant anaesthetists, two other doctors and trained theatre staff. By the time the error was rectified it was too late. This death could have been avoided.

(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.
(2)There was a lack of co-ordination and situational awareness.
(3)It became apparent that senior staff often have little experience of crisis situations and there is a danger that they become ‘de-skilled’ to some extent as a result.