Dorothy Dunn was struggling to breathe due to the swelling after she arrived by ambulance on July 12, 2017 and it was decided that an emergency “crash” tracheostomy should be performed in an attempt to “secure her airway”.
The procedure, which involves cutting a hole in the patient’s neck, was performed and a tube inserted.
Mrs Dunn, 86, from Sedgley, suffered a heart attack and five days later – on July 17 2017 – she died.
Medical notes received by her family 18 months later stated that there was “no tracheostomy kit” present when Mrs Dunn was treated.
The family say they were not informed of the absent equipment, and delays, before this and are seeking “transparency” and answers from the Dudley Group NHS Foundation Trust.
Black Country Coroner’s Court has heard that Ear, Nose and Throat specialist Dr Petru Vaida, who performed the operation, shouted that he needed a tracheostomy kit “right now” repeating his request twice, possibly three times.
He said when he received no feedback he called for a knife or scalpel and “had to repeat that request as well more than once”.
Dr Adam Hancox, an anaesthetic registrar, told the hearing today that he was attending to a sick patient with low blood pressure when he was told about Mrs Dunn.
Dr Hancox asked for 10 to 15 minutes to continue treating his patient before making for Mrs Dunn on the resuscitation ward.
Senior coroner for the Black Country, Mr Zafar Siddique said: “Do you think it was wise spending 15 minutes with the other patient in the circumstances?
“I think it is difficult to say with hindsight,” said Dr Hancox.
The court heard that when Dr Hancox arrived Mrs Dunn had a “completely obstructed airway”, and that he was “task-focussed” on organising the equipment and drugs.
No airway equipment was out and ready for use.
“I shouted ‘we don’t need anything other than a scalpel’,” said Dr Hancox who also called for assistance.
“We need more hands in here, we need more help.”
Dr Hancox explained that the anaesthetics drugs were kept in a locked drawer in the resuscitation bay and that there was a search for the keys.
“It took a few minutes for the drawers to be opened,” he said.
The coroner asked why a scalpel was not available in the resuscitation area.
“There was a scalpel in the airway trolley in resuscitation but in the moment myself, the other staff and Dr Vaida did not know it was there,” said Dr Hancox.
Richard Livingston, legal counsel for Mrs Dunn’s family asked Dr Hancox: “Would it be accurate to describe the scene as chaotic?”
Dr Hancox said any scene in an emergency room is chaotic. “It was an emotionally charged scene,” he added.
The doctor said he could not recall seeing a Difficult Airways Trolley in the resuscitation room.
Concerned over the delay in acquiring equipment and a scalpel, and that his colleagues had not received a beep notification of an anaesthetic emergency, Dr Hancox logged them as issues for review by the hospital.
Dr David Stanley, a specialist in anaesthesia at Russells Hall Hospital, told the inquest that measures had since been taken by the hospital.
He said a new ‘code red’ system is now in place for alerting staff to anaesthetic emergency which has been used successfully, and that five standardised, labelled Difficult Airway Trolleys, which hold equipment, have been bought.
“The trolley is absolutely distinctive,” he said.
“I am confident everyone would know what is meant by Difficult Airway Trolleys.”
He added that the drugs had been in a locked drawer requiring a key to access them.
“Now there is a key code mechanism,” he said.
Dr Stanley participated in a resolution meeting with Mrs Dunn’s family in October 2019.
“I felt it was my responsibility to oversee such a serious incident,” he said.
“It was a long meeting - I felt we were open and I remember trying to convey that, while it would not help their loved one, we have taken this extremely seriously since the time it happened and made lots of significant changes to reduce the chances of this happening to someone else.”
Dr Joanne Taylor, a consultant in Emergency Medicine at Russells Hall Hospital, was not clinically involved with Mrs Dunn’s case.
She told the hearing that the procedure – a front and neck access – is extremely rare in an emergency setting.
“I have been practicing for 20 years but I have never seen it done in real life,” she said.
“There are 19 consultants in the department – ten have never seen it and only three have ever done it on patients.”
Of the efforts made by hospital staff, Dr Taylor said: “They were trying their best in very difficult circumstances.
“Mr Vaida is used to doing front and neck access in a theatre when the patient is prepared.
“I appreciate there were delays but everyone in that room was doing their best to save her (Mrs Dunn’s) life.”
The inquest continues.
Report by Andy Kerr