Coroners reports

The College receives reports to prevent future deaths from the coroner when the coroner is concerned that future deaths could occur unless action is taken. We work with our fellows, members and partner organisations to ensure that the lessons learned from these tragic cases are incorporated into practice.

Patient safety lies at the heart of healthcare. It is one of the most significant concerns across the NHS and independent sector and is a key priority for the College. A key factor to driving forward patient safety is maximising the things that go right and minimising the things that go wrong. Learning from mistakes by addressing systemic factors in order to prevent future harm is essential to improving patient safety.

Unrecognised oesophageal intubation

The College recently received a coroners report where an oesophageal intubation took place and was not recognised in time to save the life of the patient. Unrecognised oesophageal intubation is preventable through adherence to published recommendations on the monitoring of exhaled carbon dioxide (capnography) and its correct interpretation. All clinicians involved in airway management should watch the College and DAS video on capnography. We ask that they always remember 'No Trace = Wrong Place' and actively seek to exclude oesophageal intubation when a flat capnograph trace is encountered.


Multidisciplinary team training

Multidisciplinary team training has an important role to play in rehearsing emergency drills, embedding non-technical skills in practice and allowing teams to learn how to function well as a whole within a flattened hierarchy. We have developed the following resources to support departments to deliver team training:

We recognise that time is the biggest barrier to team training and have thus developed three short, flash card simulations to enable this to be delivered as a talk-through scenario in 5 minutes. We ask all departments to use these flash cards on the subject of unrecognised oesophageal intubation and to provide us with feedback.

The flashcards can be downloaded here

More information about the campaign can be found in the following articles:

RCoA Bulletin January Issue

Anaesthesia News January Issue

FICM Critical Eye January  Issue

National Guardian Newsletter


Preventing unrecognised oesophageal intubation has been the subject of talks at many of our educational meetings. Below you can watch Prof Tim Cook's talk from the RCoA's Anaesthesia Updates meeting and Dr Lewys Richmond's talk from the SALG Patient Safety Conference, both of which took place in November 2021. You can also watch the full session on this topic from the Winter Symposium, which took place in December 2021. 

The coroner’s report highlights the critical importance of human factors in safe anaesthetic practice and we recommend Dr Fiona Kelly’s talk on human factors and airway emergencies, available below.

If you have any queries about our patient safety workstream, please contact us