‘Squashed’ breathing tube may have caused teenager’s death, inquest hears

  • 11/7/2022
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A teenager died after a breathing tube was possibly squashed by a wheel of her hospital trolley during emergency surgery, an inquest has heard. Jasmine Hill, 19, had a cardiac arrest shortly after undergoing a procedure on her neck at Gloucestershire royal hospital in Gloucester. The inquest heard that a report commissioned by lawyers acting for Hill’s family referred to the tube being “squashed by the wheel of a trolley”. Hill, from Cirencester, had been readmitted to the hospital after her neck became swollen five days after a thyroidectomy – the removal of all or part of the thyroid gland – in September 2020. Doctors thought the site of the surgery in Hill’s neck, which was red and swollen, may have become infected and it was decided the wound should be cleaned under general anaesthetic. The procedure took less than 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. Gloucestershire coroner’s court heard an endotracheal tube, which supports breathing, was positioned behind Hill’s head and away from her neck, fixed to a holder and connected to the ventilator. The assistant Gloucestershire coroner Roland Wooderson asked Dr Hiro Ishii, who carried out the procedure, whether he was aware that the anaesthetist had checked the position of the endotracheal tube. Ishii replied: “I didn’t make a formal inquiry at that stage.” The anaesthetic nurse Gerry Paclejan said the endotracheal tube was secured loosely to the side of the trolley with a tourniquet. “There is no way the tube will be laying on the floor – it is always on the side of the table,” he said. Corinne Slingo, representing Gloucestershire Hospitals NHS foundation trust, asked Paclejan: “At any point were you aware of any compromise to the ventilation tube?” He replied: “No.” Referring to the report commissioned by lawyers acting for Hill’s family, the coroner asked: “In Jasmine’s case, can you remember where the tubes were on that day?” Paclejan replied: “During intubation I always make sure the tube is tied up and safe before we move the patient.” A pathologist was unable to ascertain the cause of Hill’s death. The inquest is due to end on Wednesday.

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