A teenager died after her oxygen tube became blocked as she was moved onto a hospital trolley during emergency surgery, a coroner has ruled.
Jasmine Hill, 17, suffered a fatal cardiac arrest shortly after undergoing a procedure on her neck at Gloucestershire Royal Hospital.
Assistant Coroner for Gloucestershire Roland Wooderson said the most likely cause of the breathing tube obstruction was when the teenager was moved from the operating table to a recovery bed.
Recording his findings following a three-day inquest, the coroner said: “I find on balance of probabilities that the sudden catastrophic crisis faced by Jasmine was the obstruction of the inspiratory limb of the breathing system caused at the time of the rotation of the bed.
“I also find on balance of probabilities that such event more than minimally negligibly or trivially contributed towards Jasmine’s death.”
Gloucestershire Coroner’s Court heard the teenager, from Cirencester, had been re-admitted to the hospital after her neck swelled five days after undergoing 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 had failed to respond to antibiotics.
It was decided Miss Hill needed to go to theatre to clean the wound 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.
Data recovered from a surgical machine showed there was a 30-second break in the administration of oxygen via the endotracheal tube shortly before she suffered the cardiac arrest.
The court heard that Miss Hill’s family believe the ET tube had been squashed by the wheel of the trolley as she was moved.
It was also suggested she could have bitten on the tube as she coughed and began to wake up.
But expert witness Professor Jonathan Hardman said biting was unlikely as a cause because there was no evidence of damage to the tube.
Giving evidence, the consultant anaesthetist said: “In my opinion the most likely explanation for the sudden catastrophic event was an obstruction of the breathing line probably due to the rotating of the bed to aid the transfer.”
Prof Hardman said, having heard all the evidence given during the inquest, there was nothing that would lead him to change his conclusion.
Detailing his conclusions, the expert said he had ruled out other causes such as displacement of the tracheal tube and biting.
He said the presence of a pulmonary edema – the build-up of fluid in the lungs – in Miss Hill, who was young and fit and healthy, was “very unusual”.
“The only other real possibility is obstruction of the tubing going from the anaesthetic machine to the tracheal tube,” he said.
“The next observation that leads me to believe this is an obstruction of the delivery of fresh gas to Jasmine’s tracheal tube is that the progression of hypoxia was remarkably rapid.
“The only way realistically to deoxygenate this rapidly is to obstruct the supply of fresh gas.
“We know that the bed was rotated 180 degrees horizontally, meaning that the head end of the bed was akin to where the foot end was previously to allow the anaesthetist to remain standing by the anaesthetic machine and have easy access to the patient’s airway.
“That movement of the bed provides an opportunity for the wheels of the bed or any other equipment to roll over the breathing system tubing.
“There have been previous disasters described where that is exactly that has happened where the bed has been moved and obstructed breathing systems.
“I remember being told about it when I was a junior trainee back in the last century. I think it remains a possibility and a clear danger to patients.
“I believe attaching (the) breathing system to the side of the table demonstrates ongoing awareness of it being a risk.
“If the breathing system tubing was obstructed, and fresh gas supply to Jasmine’s airway was denied, it more than minimally and materially contributed to her death.”
A post-mortem examination was unable to establish the cause of the teenager’s death.
In his conclusions, Mr Wooderson said he accepted Prof Hardman’s evidence and “conclusions without reservation”.
Recording a narrative conclusion, he added: “She died as a result of complications arising during a routine operation.
“There was an obstruction in the tube leading from the hospital ventilation equipment to her endotracheal tube which compromised her ability to be oxygenated and which triggered severe pulmonary edema.
“The obstruction occurred at the time that the bed was being rotated and was likely caused by this.”
In a statement released at the end of the inquest, Miss Hill’s family said: “We’re grateful that the coroner uncovered what happened that day to our beloved Jasmine.
“She was a kind, creative and loving spirit who made such an impact on the lives of others.
“Jasmine was a timid, quiet and sometimes shy girl, and once you got to know her, she would open up, exposing her depth of character, sense of humour, intelligence, warmth and love.
“In our overwhelming grief, we have struggled to get answers from the hospital over the past two years and while it has been extremely hard to come to terms with what happened, we hope that the findings of this situation will contribute to preventing such a tragedy happening to any individual or family ever again.”
Solicitor Sevim Ahmet, from Fieldfisher who represented the family, added: “Finding the answers as to how Jasmine died was made more difficult by the trust’s conduct in disclosing evidence late and omitting key information from the records provided to the coroner’s expert.
“Without our medical expert highlighting the likely cause, Jasmine’s family would still be in the dark.
“What is now clear is that Jasmine’s death was avoidable and I know her family will take some small relief if new safety recommendations around anaesthesiology result so that other families do not suffer similar devastation.”
Professor Mark Pietroni, director of safety and medical director at Gloucestershire Hospitals NHS Foundation Trust, said: “We would like to extend our heart-felt sympathies to the family of Jasmine Hill for their tragic loss.
“We have only just received the coroner’s verdict. We will consider it carefully in order to understand its implications in detail.”