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

A teenage girl has died after a breathing tube was compressed by the wheel of her hospital cart during an emergency surgery, an investigation says.

Jasmine Hill, 19, went into cardiac arrest shortly after undergoing neck surgery at the Royal Gloucestershire Hospital in Gloucester.

The investigation heard that a report commissioned by lawyers representing the Hill family indicated that the pipe had been “crushed by a wagon wheel”.

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Hill, of Cirencester, was readmitted to hospital with a swollen neck five days after a thyroidectomy — removal of all or part of her thyroid gland — in September 2020.

Doctors believed that the surgical site on Hill’s neck, which was red and swollen, may have become infected and it was decided to clean the wound under general anesthesia.

The operation took less than an hour, and the teenage girl, who wanted to become a journalist or writer, went into cardiac arrest shortly after being carried by staff from the operating table to bed.

The Gloucestershire court heard an endotracheal tube, supporting breathing, was placed behind Hill’s head and away from her neck, attached to a stand and connected to a ventilator.

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Gloucestershire assistant coroner Roland Wooderson asked Dr Hiro Ishii, who performed the procedure, if he knew the anesthesiologist had checked the position of the endotracheal tube. “I did not conduct a formal investigation at that point,” Ishii replied.

Nurse anesthetist Jerry Bucklegan said the endotracheal tube was held loosely to the side of the cart with a tourniquet. “It is impossible for the pipe to be placed on the floor – it is always on the side of the table,” he said.

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Corinne Slingo, NHS Representative for Gloucestershire Hospitals, asked Bucklean: “At what time were you aware of any compromise for the vent tube?” he said no.

Referring to the report commissioned by lawyers representing the Hill family, the coroner asked, “In Jasmine’s case, can you remember where the tubes were that day?” Bucklegan replied, “During intubation, I always make sure the tube is tied and secure before moving the patient.”

The pathologist was unable to ascertain the cause of Hill’s death. The investigation is scheduled to end on Wednesday.

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