Woman died amid panic and chaos

Hospital staff carrying out a routine operation which went wrong showed a lack of leadership, which resulted in “panic and chaos” and contributed to a woman dying, a report has said.

Glenda Logsdail, 61, died at Milton Keynes Hospital in August 2020.

A report written by the coroner said the team carrying out her operation had “malfunctioned”.

Written by assistant coroner for Milton Keynes, Dr Sean Cummings, it said a breathing tube was “placed in the oesophagus instead of the trachea”.

This resulted in Mrs Logsdail’s blood oxygen levels falling and she eventually suffered a cardiac arrest.

In the report, Dr Cummings raised concerns that no confirmatory checks had taken place to make sure the tube had been correctly inserted.

He said the anaesthetist Dr Wael Zghaibe, who is not identified in the report but who gave evidence during the inquest, had been “fixated on a diagnosis of anaphylaxis being responsible for the collapse”.

The report said that fixation “conveyed an infectious certainty” and compromised the assessments of other staff members.

It said Dr Zghaibe “did not go back to basics and consider A (airway), B (breathing), C (circulation) to work his way through possible correctable causes”.

The report said: “There was panic and chaos in the anaesthetic room.

“There was considerable confusion as to roles and there was an absence of a leader dealing with the emergency.”

It added: “The team malfunctioned and did not operate as a team.”

The inquest into Mrs Logsdail’s death, held in July, concluded it “was wholly avoidable and was contributed to in major part by neglect”.

The report has been sent to the hospital’s chief executive Joe Harrison, chief medical officer for England Professor Chris Whitty and the president of the Royal College of Anaesthetists Dr Fiona Donald.

They have a duty to respond to the coroner within 56 days.