The wheel of a hospital trolley may have blocked a tube supplying oxygen to a teenager having emergency surgery, an inquest has been told.
Jasmine Hill, 17, suffered a deadly cardiac arrest shortly after having a procedure on her neck at Gloucestershire Royal Hospital.
Data from a surgical machine showed there was a 30-second break in the administration of oxygen to Miss Hill, with the inquest examining what may have caused that.
The teenager’s family believe a hospital trolley wheel squashed an endotracheal (ET) tube, which aids breathing, as she was moved from an operating table to a recovery bed.
Gloucestershire Coroner’s Court has heard evidence Miss Hill could have bitten on the ET tube as she coughed and began to wake up.
But expert witness Professor Jonathan Hardman said that is unlikely because there was no evidence of damage to the tube.
The consultant anaesthetist said an “obstruction of the breathing line”, due to rotating the bed to aid the transfer, is “the most likely explanation for the sudden catastrophic event”.
Prof Hardman said he heard nothing at the inquest that would warrant changing his conclusion.
He said he had ruled out other causes, such as displacement of the tracheal tube and biting.
If the breathing system tubing was obstructed and fresh gas supply to Jasmine’s airway was denied, it more than minimally and materially contributed to her death— Prof Jonathan Hardman
He said the presence of a pulmonary edema – the build-up of fluid in the lungs – in Miss Hill, who was young and fit and healthy, was “very unusual”.
“The only other real possibility is obstruction of the tubing going from the anaesthetic machine to the tracheal tube,” he said.
“The next observation that leads me to believe this is an obstruction of the delivery of fresh gas to Jasmine’s tracheal tube is that the progression of hypoxia was remarkably rapid.
“The only way realistically to deoxygenate this rapidly is to obstruct the supply of fresh gas.
“We know that the bed was rotated 180 degrees horizontally, meaning that the head end of the bed was akin to where the foot end was previously, to allow the anaesthetist to remain standing by the anaesthetic machine and have easy access to the patient’s airway.
“That movement of the bed provides an opportunity for the wheels of the bed or any other equipment to roll over the breathing system tubing.
“There have been previous disasters described where that is exactly that has happened – where the bed has been moved and obstructed breathing systems.
“I remember being told about it when I was a junior trainee back in the last century. I think it remains a possibility and a clear danger to patients.
“I believe attaching breathing systems to the side of the table demonstrates ongoing awareness of it being a risk.
“If the breathing system tubing was obstructed and fresh gas supply to Jasmine’s airway was denied, it more than minimally and materially contributed to her death.”
The inquest was told Miss Hill, from Cirencester, Gloucestershire, had been readmitted to hospital after her neck swelled five days after undergoing a thyroidectomy in September 2020.
Doctors thought the site of the surgery in her neck may have been infected after the wound became red and swollen and had failed to respond to antibiotics.
It was decided Miss Hill needed to go to theatre to clean the wound under general anaesthetic.
The procedure took under an hour and the teenager, who wanted to be a journalist or writer, went into cardiac arrest shortly after she was moved by staff from the operating table to a bed.
The inquest continues.
