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If there had been no proper transfer of care from Dr A to the recovery nurses, it wasentirely inappropriate for him to go back to theatre and start another operation; he has acontinuing duty of care to his patients that has not been discharged. Even if there hadbeen a transfer of care, in such a case, I would expect the anaesthetist to stay with thepatient until they had recovered and to find someone else to anaesthetise the rest of theoperating list. The situation with Mrs Bromiley was far from satisfactory as the recoverynurses were not given the appropriate support from Dr A and they became increasinglyconcerned about her condition. From the statements of the recovery nurses and bothanaesthetists, it is clear that there were obvious signs of cerebral irritation that neededintensive care.Care in recoveryGiven her condition and the inappropriateness of her transfer to recovery, I believe thatthe recovery staff provided good care to Mrs Bromiley. They were clearly concernedabout her condition but did not seem to have the degree of support that they might expectfrom Dr A. If there is a criticism, it relates to the lack of written recording for the periodof stay in recovery. Having spoken to the staff involved, I believe that the record musthave been mislaid.Transfer to intensive care unitAs I have already stated, in my opinion, Mrs Bromiley should not have been admitted torecovery but gone directly to intensive care, but only after a patent airway had beensecured. In the event, when it was decided to transfer Mrs Bromiley, it was done withouta secured airway. When she arrived at (NHS) Hospital, there were again problems withintubation and only after several attempts was it possible to pass a tracheal tube andsecure the airway.It would have been more appropriate, in my opinion, for Mrs Bromiley to have had herairway secured before transfer. Those already in the theatres were aware of the problemsand would have thought out how to get around the difficulties, or they could havesummoned appropriate skilled assistance from other colleagues elsewhere to come to Thexx Clinic where all the necessary staff and equipment were available. Transferring suchan unstable patient without a secure airway was an unnecessary risk.Management in (NHS) General HospitalAs I alluded to earlier, this is an area of care outside the terms of reference for the inquirybut I believe, Mrs Bromiley received the best possible care but unfortunately the damageto her brain caused by the prolonged period of hypoxia was so extensive that recoverywas unlikely.14
Conclusions and suggested actionsAs is clear from the report, I believe that Mrs Bromiley suffered severe cerebral damageas a result of her extended period of hypoxia subsequent upon the unexpected difficultyin maintaining her airway during anaesthesia.The staff and facilities at The xx Clinic are of a high standard. There is a good level ofequipment in the hospital to deal with difficult airways. The only piece of equipment notavailable at the time of my visit in May was an Aintree Catheter. It would be prudent toprovide this piece of equipment.Suggested action: Purchase of Aintree Catheter for use in difficult intubationThe pre-operative assessment and anaesthetic management was of an appropriatestandard as was the choice of anaesthetic technique and drugs.The initial airway management was appropriate and in keeping with acceptable practice.The management of the „can‟t intubate, can‟t ventilate‟ situation did not follow theaccepted Difficult Airway Society guidelines. In particular too much time was taken intrying to intubate the trachea rather than concentrating on ensuring adequate oxygenationby other means such as direct access to the trachea. Whilst theatre staff ensured that allnecessary equipment was available, the clinicians appeared to become oblivious to thepassing of time and thus lost opportunities to limit the extent of damage caused by theprolonged period of hypoxia. Given the skill mix of the clinicians, it would have beenvery easy to perform a surgical procedure to gain access to the trachea. Theatre staff,when interviewed, all seemed surprised that such was not performed. Suggested action:Ensure an atmosphere of good communication in the operating theatre such that anymember of staff feels comfortable to make suggestions on treatment.The Difficult Airway Society guidelines are fairly new (2004) and it may be useful tohave copies of them on display in the anaesthetic rooms to act as a prompt should such anevent occur again.Suggested action: Obtain and display a set of the latest DAS guidelines in eachanaesthetic roomGiven the problem with time passing unnoticed, should such an event occur again, amember of staff should be allocated to record timings of events and keep all involvedaware of the elapsed time.Suggested action: Develop a protocol to ensure that when any emergency event occurs,be it in the anaesthetic room or the operating theatre, there is someone designated to keepfull contemporaneous records of the event and to provide an elapsed time prompt. It wasclear that clinicians were not entirely familiar with some of the particular peculiarities ofsome of the equipment used. This might be rectified by a study day on difficult airwaymanagement for all staff including clinicians.15
Page 6 and 7: The proposed plan was for a general
Page 8 and 9: 08.47-08.50 Further attempts at lar
Page 10 and 11: Appropriateness of clinical managem
Page 12 and 13: These are well recognised technique
Page 16 and 17: Suggested action: Organisation of a
Page 18: Corrected timeline based on Prof Ha

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