A doctor involved in the care of a 22-year-old mum who died in hospital said 'probably not a lot of thought' went into a decision made prior to her death. Jodie McCann, who had previously received treatment at the King's Mill Hospital, was transferred while being ventilated to Queen's Hospital in Burton on March 22 last year.
Dr Paul Richard Smith, who was involved in Ms McCann's care in Burton, gave evidence during an inquest examining her death on Thursday, March 30. He explained that the 22-year-old patient went through what "can be challenging process" when she was extubated on March 28. Extubation is the process of taking out a tube that helps one breathe.
Ms McCann had to be reintubated later that evening by two junior doctors who were on call. Dr Elizabeth Didcock, leading the inquest at Nottingham Council House, described that as "concerning", adding: "It strikes me that it was always going to be difficult in Jodie's case."
Are you planning an event for King Charles III’s Coronation? Let us know here
She has asked Dr Smith: "Jodie on that day had a truly urgent extubation. Was there any thought occurring because these doctors would be very challenged in an emergency situation."
Dr Smith, answering the question, told the hearing: "Probably not a lot [of thought]." However, he explained this has been recognised since and junior doctors are no longer on out-of-hour calls.
Another measure has been introduced into their practice since the incident, Dr Smith told the hearing. Individual forms for patients were re-introduced and have been in use for more than a year.
But a couple of days later, Ms McCann became "agitated", and Dr Smith told the inquest that her behaviour was due to the misplacement of the tracheostomy tube, which was displaced at some point. He explained that the tube used on Ms McCann was their 'least favourite' because it was more flexible and could move with the appearance of being in the right place.
It also became apparent that a small tube in the airway trolley was missing as it was broken at the time of the procedure. Dr Smith had then proceeded to perform 'escalating airway manoeuvres'.
This lateral approach, Dr Smith said, lasted around "17, 18, 19 minutes". "In hindsight, this would have probably lasted around five, six minutes in cardiac arrest. If I was able to start the resuscitation would have been more successful."
Coroner Dr Didcock went on and asked: "On balance of probabilities, would have Jodie survived?" Dr Smith answered: "In general, the survival from cardiac arrest is low. The prognosis in my mind is still low because other things have to happen to get the patient stable."
Adam Korn, representing Jodie's family in court, asked Dr Smith if he has ever encountered this situation before in his career. Dr Smith said he performed a tracheostomy on Jodie while she was having her third cardiac arrest since being transferred to Burton. "This is the first time I have encountered this," he told the hearing.
Ms McCann was originally from Salford but later moved to Nottinghamshire and had just enrolled to start training as a nurse at the time of her death, at the Queen's Hospital on April 2. She'd initially been admitted to the King's Mill Hospital, in Sutton-in-Ashfield, on March 16 last year and was found to have gallstone pancreatitis.
The inquest continues.
READ NEXT:
