Cognitive bias results in death after incorrect intubation
York based medical negligence specialists, Pryers Solicitors LLP, who were instructed to represent the family of a woman who died at Charing Cross Hospital, have helped them to get the closure they deserve.
The inquest into the death of a 46 year old woman, who died whilst in Intensive Care at London’s Charing Cross Hospital, has concluded that mistakes by the medical team contributed towards her death. The Coroner found that, instead of relying on their training, staff wrongly assumed that the medical monitoring equipment was faulty, so did not realise that her breathing tube had been misplaced, for over an hour.
In October 2019, Ms Naomi Ryan was admitted to Charing Cross Hospital with a three day history of pneumonia.
After arriving at the Emergency Department, she was quickly transferred to the Intensive Care Unit. However, on arriving in Intensive Care, she went into cardiac arrest and had to be revived. After reviving her, the decision was made to put her on a ventilator to relieve some of the stress on her heart. However, when intubating her, the breathing tube was passed into her stomach rather than into her lungs, which meant that she was deprived of oxygen.
Despite a carbon dioxide monitor - used to ensure lung function was normal during ventilation – alerting that there was a problem, the medical team assumed that the device was faulty and tried at least three other monitors. After 20 minutes of unsuccessful CPR the team called the ‘on-call’ consultant, who was at home; she advised them to provide medication and continue CPR for a further 20 minutes, and she would come in. Shortly after arriving, the consultant identified that the breathing tube had not been placed correctly and replaced it immediately.
After correcting the breathing tube, Naomi’s breathing returned to normal, but she had been starved of oxygen for 1 hour and 17 minutes and never regained consciousness. She leaves behind a large family and a loving partner.
An internal investigation by the hospital found that the clinicians had a cognitive bias towards equipment failure, so did not follow the usual procedure. At the inquest, it was found that the medical team’s reliance on each other’s competence, had resulted in them failing to check their work. Additionally, it transpired that an important piece of training, provided earlier in the same year specifically about this scenario, had not been distributed to staff by the Trust’s management.
At the inquest earlier this month, Her Majesty’s Coroner of West London found that it did not occur to Naomi’s care team that rising carbon dioxide levels in her blood could have been due to a misplaced breathing tube, and that this error had contributed towards Naomi’s death.
Senior Solicitor, Tamlin Bolton said: “The loss of Ms Ryan was a wholly avoidable tragedy. This was a basic error and a fundamental failure in the most elementary part of ICU care. Cognitive bias in medicine must be considered a serious concern in the training and discipline of all junior doctors. In stressful emergency situations, communication and the ability to openly question your peers, is vital. The doctors admitted to the coroner, that if they had worked through their training, they would have recognised that the most obvious cause for the rising carbon dioxide levels, was that the breathing tube was not in the right place”.
The hospital has since apologised to the family and admitted that their negligent care led to her death. Pryers Solicitors are working to resolve the claim for compensation as swiftly as possible.
Read the full story here:
https://www.pryers.co.uk/news/incorrect-intubation-leads-to-death-of-46-year-old-woman/
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