Milton Keynes hospital doctor tells inquest mistake was 'grave error'

The family's barrister Neil Sheldon QC described the error as a "basic and catastrophic" mistake

A former NHS radiographer died after a breathing tube was wrongly inserted in her throat during an operation, an inquest heard.

Anaesthetist Dr Wael Zghaibe told the hearing he made a "grave error", after mistakenly inserting a breathing tube.

Glenda Logsdail died at Milton Keynes University Hospital in August, after her blood oxygen levels plunged and she suffered a cardiac arrest while being prepared for theatre.

Dr Zghaibe said he had misdiagnosed.

The 61-year-old mother was being prepared for a septic appendicitis operation, which has an expected 99% chance of survival.

The inquest was told that instead of taking oxygen into the lungs, the tube directed oxygen into her stomach - known as oesophageal intubation.

Dr Zghaibe said he misidentified the patient's reactions, wrongly believing she was suffering a potentially life-threatening allergic reaction, known as anaphylaxis, to the pre-operative medication.

"I did not suspect at that point or any point, for that matter, it was a tube-related issue," he said.

'Catastrophic' mistake

When monitors showed Mrs Logsdail's carbon dioxide levels had dropped to virtually nothing, Dr Zghaibe "started linking symptoms" to make the incorrect diagnosis.

Some 15 minutes later a more senior consultant arrived and on checking, discovered the tube was in the wrong place.

Asked by assistant coroner Dr Sean Cummings at Milton Keynes Coroner's Court if he should have considered misplaced intubation, Dr Zghaibe replied: "I do."

Mrs Logsdail's family barrister Neil Sheldon QC described the error as a "basic and catastrophic" mistake.

He asked the doctor: "Just so we are clear, the only thing you would have needed to do to identify this mistake would have been to pick up the laryngoscope in the room and check the position of the tube, agreed?"

Dr Zghaibe replied: "Correct."

The hearing was told that in 2018 the Royal College of Anaesthetists created a training video directly relating to lack of CO2 output being symptomatic of incorrect intubation.

The inquest continues.