07 July 2021

Junior doctor looked at wrong monitor for key airway reading, inquest told

07 July 2021

A junior doctor has told an inquest she failed to spot a patient’s breathing output had flat-lined because she was looking at the wrong monitor.

Married mother-of-two Glenda Logsdail died at Milton Keynes University Hospital on August 23 2020, after her blood oxygen levels plunged and she suffered a cardiac arrest as she was being prepared for theatre.

She was originally admitted to have surgery for septic appendicitis – a procedure the inquest previously heard had a 99% chance of survival.

The coroner has already heard evidence from experienced consultant anaesthetist Dr Wael Zghaibe, who told how he made a “grave error” by wrongly inserting Mrs Logsdail’s breathing tube and then failing to spot his mistake.

As Mrs Logsdail’s condition got rapidly worse, doctors in the room including Dr Zghaibe told how they did not make what the coroner described as the “basic” checks of airway, breathing and circulation, known as “ABC checks”.

Milton Keynes University hospital (PA Archive)

Milton Keynes Coroner’s Court heard on Wednesday that as 61-year-old Mrs Logsdail, a retired NHS consultant radiographer, went into cardiac arrest, other medics rushed to the anaesthetic room to assist.

One of those clinicians, Dr Shraddha Kamath, an anaesthetic and intensivist registrar trainee, told the coroner she saw displayed on a nearby monitor that Mrs Logsdail’s blood oxygen saturation level was at 81%, well below the normal range.

She said she had “sensed, while outside the room, something was wrong”, before going in to help.

The coroner previously heard the room’s machine monitors were also showing Mrs Logsdail’s output of carbon dioxide (CO2) – known as the “end tidal CO2 trace” measurement – and would have pointed to a problem with her breathing, but were over-looked.

The measuring of carbon dioxide – a by-product of normal breathing – is a key marker of a patient’s “breathing circuit”, with the inquest hearing evidence Mrs Logsdail’s readings had dropped to virtually nothing within minutes.

Dr Kamath gave evidence that the CO2 trace measurement was displayed on the same screen as the blood oxygen reading she had noted earlier, but “further down the screen”.

But instead, she “mistakenly” concluded there was a carbon dioxide output reading after misidentifying a monitor recording air-flow from the ventilator as the CO2 machine.

She said: “I saw a wave-form on the ventilator monitor, which I took to be the end tidal CO2 trace – mistakenly.”

Neil Sheldon QC, representing Mrs Logsdail’s family at the inquest, asked Dr Kamath: “So, prior to oesophageal intubation, you were never aware that the end tidal CO2 trace for Mrs Logsdail was flat, is that right?

“No,” she replied.

It never occurred to me that I could have made such a grave error

What had not been identified by anybody in the room at that point was that Mrs Logsdail’s ventilation tube, inserted to aid her in breathing during surgery, had been wrongly placed.

Instead of taking oxygen into the lungs, the tube was directing oxygen into her stomach – known as oesophageal intubation.

In his evidence on Tuesday, Dr Zghaibe said he believed Mrs Logsdail was suffering an allergic reaction to pre-operative drugs, known as anaphylaxis – a potentially life-threatening condition.

He told the coroner: “It never occurred to me that I could have made such a grave error.

“Because I was focused (on anaphylaxis) – that that was my diagnosis.”

The coroner also heard how Dr Zghaibe initially allowed an “unqualified” colleague to first attempt the intubation, but then inserted the endotracheal (ET) tube himself after it was unsuccessful.

It was 15 minutes after the incident began, when a senior colleague arrived and spotted what the Logsdail family’s barrister described in court as a “basic and catastrophic” mistake with the intubation.

The main finding of a formal expert report, ordered by the coroner before inquest, concluded Mrs Logsdail “died from a hypoxic brain injury due to the unrecognised placement of a tracheal tube in the oesophagus at the start of surgery for acute appendicitis, and that this death was preventable”.

The inquest into the death of Mrs Logsdail, who had previously worked at London’s Royal Marsden and Northampton General Hospital until retiring in 2017, continues.

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