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Tracheostomy troubles

01 May 2008

Mr A was a 50-year-old lecturer in general good health. In a private hospital, he underwent an elective laparotomy for diverticular disease. Postoperative complications ensued with subsequent peritonitis. Following a period of ventilation in intensive care, he was left with a temporary tracheostomy for respiratory care.

Dr B, who was an experienced consultant anaesthetist, inserted the tracheostomy percutaneously. The procedure was uneventful and Mr A made good progress. Within a few days Mr A's general condition had improved sufficiently for him to be discharged to a general ward with the tracheostomy tube still in place. Crucially, Dr B gave no special instructions about the management of the tracheostomy, either to the ward medical staff or the nursing staff.

Within 24 hours of arrival on the ward Mr A complained of respiratory difficulty. Dr S, an F2 doctor, saw him, but was unfamiliar with the care of the tracheostomy tube. He could not work out how to clear the blockage or improve Mr A’s breathing. Shortly afterwards Mr A experienced a respiratory arrest culminating in his death. Efforts to resuscitate him were greatly hampered by the lack of familiarity of the resuscitation team with the tracheostomy.

The subsequent postmortem confirmed that Mr A had died as a result of an obstructed tracheostomy.

The family made a claim of negligence against the hospital, Dr B and Dr S.

Expert opinion

This concluded that Mr A's general condition was indeed stable enough for him to have been transferred to a ward. Opinion was sharply critical of Dr B for failing to establish whether or not the ward staff were familiar with tracheostomy care. The expert was also critical of the ward staff for accepting the patient, despite their lack of familiarity with tracheostomy care. The expert was supportive however of Dr S. He concluded that Dr S could not reasonably have been expected to be familiar with tracheostomy care.

There was criticism too for the resuscitation team. It was felt that their overall response to the situation was poor, and that they appeared to have been poorly trained.

The claim was held to be indefensible in the circumstances, with liability being divided equally between MPS, on behalf of Dr B, and the hospital.

Learning points

  • Adverse events are often due to a combination of systems failures and human error or negligence. Clinical governance has a key role in helping to reduce these.
  • Hospitals must ensure that they provide suitably trained resuscitation teams and equipment. Systems should be in place for regular updates for staff. Audits should be carried out to monitor performance and direct improvements where necessary.
  • Patients with tracheostomy tubes should be cared for in an appropriate environment and by staff who are suitably trained. This includes familiarity with the tracheostomy airway, tracheostomy tubes and equipment, and potential complications.

Reference

Regan K and Hunt K, Tracheostomy management, Continuing Education in Anaesthesia, Critical Care & Pain, 2008; 8: 31–35.

Good Medical Practice, General Medical Council, UK (2006).

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