A teenager may have died because her breathing tube was run over and blocked by the wheel of a hospital trolley, an inquest has heard.
Jasmine Hill, 17, went into cardiac arrest shortly after having surgery on her neck at Gloucestershire Royal Hospital in September 2020.
She had a thyroidectomy five days earlier but was readmitted and operated on as doctors believed her wounds had become infected.
Data from a surgical machine showed a 30-second break in the administration of oxygen via her endotracheal tube.
Jasmine’s family believe the tube may have become trapped as she was moved from the operating table to a recovery bed, Gloucestershire Coroner’s Court was told.
Professor Jonathan Hardman, a consultant anaesthetist, said an “obstruction of the breathing line”, due to rotating the bed to aid the transfer, is “the most likely explanation for the sudden catastrophic event”.
He said a theory she may have woken and bitten the tube by accident was unlikely as there was no damage to it.
Prof Hardman told the inquest: “We know that the bed was rotated 180 degrees horizontally, meaning that the head end of the bed was akin to where the foot end was previously, to allow the anaesthetist to remain standing by the anaesthetic machine and have easy access to the patient’s airway.
“That movement of the bed provides an opportunity for the wheels of the bed or any other equipment to roll over the breathing system tubing.”
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He continued: “There have been previous disasters described where that is exactly that has happened – where the bed has been moved and obstructed breathing systems.
“I remember being told about it when I was a junior trainee back in the last century. I think it remains a possibility and a clear danger to patients.
“If the breathing system tubing was obstructed and fresh gas supply to Jasmine’s airway was denied, it more than minimally and materially contributed to her death.”
The procedure on Jasmine, who was from Cirencester in Gloucestershire, took less than an hour, the coroner was told.
The inquest continues.
