Neglect in basic care contributed to death of woman in hospital – coroner
The death of a retired NHS radiographer was contributed to by neglect in basic care a coroner has concluded, after a senior doctor’s “gross failure” to spot her breathing tube was incorrectly placed.
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 surgery.
Mrs Logsdail, 61, was originally admitted to have an operation for septic appendicitis – a procedure the inquest previously heard had a 99% chance of survival.
The inquest heard that highly experienced locum consultant anaesthetist Dr Wael Zghaibe mistakenly inserted Mrs Logsdail’s endo-tracheal (ET) tube in her throat so that air was going into her stomach rather than lungs.
He then made what Dr Zghaibe himself described as a “grave error” by failing to carry out basic airway checks.
He instead misdiagnosed the deterioration in condition of Mrs Logsdail – who had worked at London’s Royal Marsden and Northampton General Hospital until retiring in 2017 – as a type of allergic reaction to preoperative drugs, or anaphylaxis.
Dr Zghaibe became “fixated” on the diagnosis to the extent it was “contagious” to other colleagues, who had rushed to help in the “chaos” of the anaesthetic room.
The hospital trust has apologised for the “catastrophic human error”, adding it took “full responsibility” and had strengthened training, policies and procedures.
Assistant coroner Dr Sean Cummings, delivering his conclusions on Thursday, said Dr Zghaibe’s failure to “go back to basics” and check the tube position, amounted to a “gross failure to provide basic medical care”.
I find the failure to check the position of the tracheal tube amounted to gross failure to provide medical care. Consequently, I find Mrs Logsdail's death was contributed to by neglect on the part of Dr Zghaibe
He said: “There is no evidence of any confirmatory checks … to check correct placement of the ET tube.
“Dr Zghaibe did not go back to basics and consider airway, breathing and circulation (ABC) to work his way through possible correctable causes.
“Had he conducted the basic ABC checks when things first began to deteriorate, I find it is probable Mrs Logsdail would have survived.
“I find the failure to check the position of the tracheal tube amounted to gross failure to provide medical care.
“Consequently, I find Mrs Logsdail’s death was contributed to by neglect on the part of Dr Zghaibe.”
He added: “Her death was wholly avoidable and contributed to in major part by neglect.”
Dr Cummings accepted the “candid and honest” account Dr Zghaibe gave to the inquest, that he “erroneously became fixated on a diagnosis of anaphylaxis”.
Dr Zghaibe previously told Milton Keynes Coroner’s Court: “It never occurred to me that I could have made such a grave error.”
We take full responsibility for what happened and take the coroner’s conclusion neglect contributed to Mrs Logsdail’s death extremely seriously
Mrs Logsdail was admitted to A&E on August 18 last year.
But as a result of the ET tube error going unrecognised, Mrs Logsdail went into cardiac arrest within minutes and her brain was starved of oxygen “for a prolonged period”.
It was 15 minutes later, when a more senior consultant colleague arrived and identified the tube error, that the mistake was corrected.
By then, Mrs Logsdail “had suffered irreversible brain damage”, the coroner added.
It also emerged that during the pre-operative preparations, Dr Zghaibe had – without patient consent or the knowledge of hospital chiefs – allowed an unqualified theatre assistant to attempt the initial intubation, unsuccessfully.
Dr Cummings heard expert evidence that “this impromptu training session” had been “inappropriate”, not least because it was “an emergency case”.
The inquest also heard from several other medics who responded to Mrs Logsdail’s deteriorating condition.
One junior doctor told the inquest she failed to spot Mrs Logsdail’s breathing output had flatlined because she was looking at the wrong monitor.
Another more experienced anaesthetic colleague of Dr Zghaibe’s immediately saw Mrs Logsdail was “cyanosed” or discoloured from a lack of oxygen and asked “is the tube in the right place”, but did not then follow up her query.
Dr Bernadetta Sawarzynska-Ryszka told the inquest: “I came to help a senior anaesthetist, who in my mind would have followed all the anaesthetic rules.”
This tragic event has taken away a loving wife, mother and grandmother. We hope such basic errors in care never happen again and no other family has to go through such heartache
The inquest also heard that nobody in the room checked a nearby carbon dioxide output monitor, known as the “gold standard” for checking ET tube position, which would have showed Mrs Logsdail’s breathing had flatlined.
The coroner said he would prepare a report for the prevention of future deaths following the hearing.
Speaking after the inquest, Dr Ian Reckless, medical director at Milton Keynes University Hospital NHS Foundation Trust, said the “harrowing” inquest was a “terrible tragedy for (Mrs Logsdail’s) family and has deeply impacted those staff involved in her care”.
“We take full responsibility for what happened and take the coroner’s conclusion neglect contributed to Mrs Logsdail’s death extremely seriously,” he said.
Kate Rohde, of law firm Fieldfisher, representing the family, said “clear failings emerged in this sad case” and it was “important they are used as a learning opportunity”.
Mrs Logsdail’s family said in a statement: “This tragic event has taken away a loving wife, mother and grandmother.
“We hope such basic errors in care never happen again and no other family has to go through such heartache.”
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