An Inquest is underway at Milton Keynes Coroner’s Court, in relation to the death of Glenda Logsdail on the 23rd August 2020, at Milton Keynes University Hospital. Mrs Logsdail was a married, 61 year old, retired radiographer with 2 children. She had been admitted with septic appendicitis and required surgery to remove her appendix. It was noted at the Inquest that this procedure usually had a 99% chance of survival.

The Inquest heard from Dr Wael Zghaibe, Consultant Anaesthetist, who advised that he had wrongly inserted the breathing tube, and had not noticed his mistake. Instead of placing the tube so that oxygen was taken to the lungs, the tube was directing the oxygen to her stomach. Dr Zghaibe described his error as “grave”.

Mrs Logsdail’s condition deteriorated, and the doctors failed to check her airway, breathing and circulation, known as “ABC checks”, which the Coroner described as “basic” care.

Sadly, during the procedure, her blood oxygen levels plummeted and she suffered a cardiac arrest.

Once Mrs Logsdail had gone into cardiac arrest, other doctors rushed to the room to assist. One doctor advised that the display on one of the monitors showed that her blood oxygen saturation level had fallen below 81%, which is significantly below the normal range and evidence that she was not breathing correctly.

The monitors were also displaying the output of carbon dioxide, which would have indicated a problem with her breathing, but this was overlooked. Carbon dioxide is produced during the breathing process, and released during exhalation.

A Junior Doctor advised the Inquest the she failed to spot that Mrs Logsdail’s breathing output had flatlined, because she was looking at the wrong monitor.  The Carbon dioxide measurement was displayed on the same screen as the blood oxygen reading. However, the Junior doctor incorrectly identified the recording of the air-flow from the ventilator, as the carbon dioxide output. She had missed that Mrs Logsdail’s carbon dioxide output had dropped to almost nothing within a few minutes, indicating that she was not breathing.

It was only recognised 15 minutes after the cardiac arrest, when a senior colleague arrived, that the breathing tube had been incorrectly positioned. However, sadly, by this stage, it was too late.

A formal expert report concluded that 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 death was preventable”.

The Inquest into her death continues.

The team at Ringrose Law has experience in dealing with such inquests and can support and represent families at these very difficult times. If you wish to talk to a member of our team please contact us directly 

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