The Royal College of Anaesthetists and the Difficult Airway Society (DAS) would like to convey our deepest sympathies to the family of Glenda Logsdail, whose death last year during an anaesthetic was the subject of a recent coroner’s inquest. Unrecognised oesophageal intubation – the cause of her death – is preventable through adherence to published recommendations on the monitoring of exhaled carbon dioxide (capnography) and its correct interpretation.
The College and DAS will continue to work hard to deliver and promote our educational work on the importance of monitoring and interpreting exhaled carbon dioxide levels during anaesthesia and all other clinical settings in which airway management is undertaken.
We are committed to working on the recommendations set out in the coroner’s report of this case. Mistakes such as these must not be repeated. We ask that all clinicians involved in airway management watch and promote the College and DAS video on capnography. We ask that they always remember “No Trace = Wrong Place” and actively seek to exclude oesophageal intubation when a flat capnograph trace is encountered.
Dr Russell Perkins, Chair of the Research and Clinical Quality Board at the Royal College of Anaesthetists
Professor Tim Cook, advisor on airway at the Royal College of Anaesthetists
Dr Barry McGuire, President of the Difficult Airway Society