Tom represented the family of a young mother who died on 5th September 2020 following the misplacement of an endo-tracheal tube.
Emma Currell, who was aged 32, was returning home from dialysis when she suffered a seizure. Ms Currell returned to hospital and experienced a second seizure in the Emergency Department. A decision was made to insert an endo-tracheal tube prior to a CT scan.
The inquest heard evidence that the tube was inserted into her oesophagus, and there was no carbon dioxide trace detected after insertion.
The Royal College of Anaesthetists publicised the risks associated with a lack of carbon dioxide trace in their campaign ‘No Trace = Wrong Place’ in 2019.
HM Assistant Coroner Graham Danbury found that the significance of the lack of trace was not appreciated or acted upon by clinicians for an extended period of time, and returned a narrative conclusion.