Trolley wheel ‘may have blocked tube’ – inquest
ATEENAGER died after her oxygen tube was possibly blocked by a wheel of a hospital trolley during emergency surgery, an inquest has heard.
Jasmine Hill, 19, suffered a cardiac arrest shortly after undergoing a procedure on her neck at Gloucestershire Royal Hospital.
The teenager, from Cirencester, had been re-admitted to the hospital after her neck became swollen five days after a thyroidectomy in September 2020.
Doctors thought the site of the surgery in her neck may have been infected after the wound became red and swollen and failed to respond to antibiotics.
Gloucestershire Coroner’s Court heard that an ear, nose and throat specialist attempted to use a needle to relieve the swelling, but when that failed they decided Miss Hill needed to be taken to theatre to have the wound cleaned under general anaesthetic.
The procedure took less than an hour and the teenager, who wanted to be a journalist or writer, went into cardiac arrest shortly after she was moved by staff from the operating table to a bed.
Dr Mahesh Shetty, an on-call anaesthetist, said he was beginning the process of bringing Miss Hill round when she collapsed.
The court heard the endotracheal tube, which supports breathing, was positioned behind Miss Hill’s head and away from her neck and was fixed to a holder and connected to the ventilator.
“If there is a blockage and the pressures go below a certain level, it alarms,” Dr Shetty said.
He said it was “probably less than 30 seconds” between Miss Hill going into cardiac arrest and resuscitation beginning.
Assistant Gloucestershire coroner Roland Wooderson asked Dr Hiro Ishii, who carried out the procedure on Miss Hill, whether he was aware that the anaesthetist had checked the position of the endotracheal tube.
Dr Ishii replied: “I didn’t make a formal inquiry at that stage.”
Anaesthetic nurse Gerry Paclejan said the endotracheal tube was secured loosely to the side of the trolley with a tourniquet.
“There is no way the tube will be laying on the floor – it is always on the side of the table,” he said.
Corinne Slingo, representing Gloucestershire Hospitals NHS Foundation Trust, asked Mr Paclejan: “In Jasmine’s case, at any point were you aware of any compromise to the ventilation tube?”
He replied: “No. I remember it because I always looked at the tube as the anaesthetist moves the patient closer to the machine.”
Mr Wooderson referred to a report commissioned by lawyers acting for Miss Hill’s family which referred to the tube being “squashed by the wheel of a trolley”.
He asked the witness: “In Jasmine’s case, can you remember where the tubes were on that day?”
Mr Paclejan replied: “I can’t remember the actual time. During intubation I always make sure the tube is tied up and safe before we moved the patient.”
The inquest heard that a pathologist was unable to ascertain the cause of Miss Hill’s death.
Dr Stephen Leadbetter told the inquest: “I don’t think I can from the pathological evidence.
“The cause of death is one of those sets of circumstances where it is the expertise of others that allows a view to be taken.”
The inquest continues, and is due to last until tomorrow.