Resources: unrecognised oesophageal intubation

We've rounded up some useful videos that you can watch, whether you're on a coffee or lunch break, or have more time to dive deep.

Preventing unrecognised oesophageal intubation has been the subject of talks at many of our educational meetings. Below you can watch Prof Tim Cook's talk from the RCoA's Anaesthesia Updates meeting and Dr Lewys Richmond's talk from the SALG Patient Safety Conference, both of which took place in November 2021. You can also watch the full session on this topic from the Winter Symposium, which took place in December 2021. 

The coroner’s report highlights the critical importance of human factors in safe anaesthetic practice and we recommend Dr Fiona Kelly’s talk on human factors and airway emergencies, available below.

If you have a 20 minute coffee break:

Listen to Dr Lewys Richmond talk at the SALG conference about past cases of unrecognised oesophageal intubation, what has been done nationally to address this issue and what you can do locally to prevent unrecognised oesophageal intubation.

Listen to Dr Fiona Kelly, Chair of the DAS Human Factors group, talk about human factors and ergonomics, what they are, how they influence airway emergencies and some practical tips to improve your team’s response to airway emergencies.

If you have 30 minutes:

Listen to Professor Tim Cook, RCoA Airway Lead, do a deep dive into the subject of unrecognised oesophageal intubation, what has (and has not) changed since NAP4 and what you need to know to prevent unrecognised oesophageal intubation.

If you have time to immerse yourself:

Filmed at the Winter Symposium 2021, in the presence of representatives from the Logsdail family, listen as we explore the lessons to be learned from the death of Glenda Logsdail, who sadly died as a result of unrecognised oesophageal intubation.

First, Dr David Bogod introduces the session and Dr Christopher Kearns (who advised the coroner in Mrs Logsdail’s case) details the events that led to Mrs. Logsdail’s death and the conclusions reached by the coroner.

Second (from 11:53), Prof Helen Higham (who advised the hospital trust during their inquiry into Mrs Logsdail’s death) puts these events into the context of using a human factors approach to investigating serious incidents.

Third (from 30:11), Dr Navreet Ghuman and Dr Amelia Robinson (who work in the department of anaesthesia in the hospital where Mrs Logsdail died) explain the effects that Mrs Logsdail’s death has had on their colleagues and them personally.

Fourth (from 49:50), Dr Russell Perkins (RCoA Vice-President) details the College’s response to this case.

Fifth (from 1:03:38), Dr Fiona Kelly, on behalf of Martin Bromiley (Founder, Clinical Human Factors Group) reflects his comments on Mrs Logsdail’s case.

Sixth (from 1:12:18), Mr Richard Logsdail (Mrs Logsdail’s husband) and Ms Kate Rohde (legal representative of Mrs Logsdail’s family) provide their reflections on the session.

Finally (from 1:19:44), the panel of speakers hold a Q&A session, chaired by Dr David Bogod.