Ololade Olaobaju · Prevention of Future Deaths report

On 5 March 2014 I commenced an investigation into the death of Ololade Olaobaju. The investigation concluded at the end of the inquest on 27 November 2015. The conclusion of the inquest was: Natural Causes to which unsuccessful medical attempts at intubation contributed.

On 26 February 2014 Ms Olaobaju was treated at University Hospital Lewisham for progressive respiratory failure after developing community acquired pneumonia. She was transferred to the ICU where a decision was taken to intubate for mechanical ventilation. Attempts at intubation, needle cricothyroidotomy and “Quicktrack” were unsuccessful. During an attempt at establishing surgical tracheostomy by an ENT surgeon, Ms Olaobaju suffered a cardiac arrest from which she could not be resuscitated.

The medical cause of death was: 1a respiratory failure 1b Acute Lung Injury 1c Community Acquired Pneumonia 2 Recent third trimester delivery with uterine infection causing on-going vaginal bleeding.

(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.

I appreciate that this is an uncommon situation in a specialist area and I understand that you may consider it necessary to forward this report to, for example, the Difficult Airway Society.