A teenager died shortly after routine surgery when a breathing tube became blocked, possibly when it was squashed by the wheels of her recovery bed, a coroner has concluded.
Jasmine Hill, 17, had a fatal cardiac arrest soon after undergoing a procedure on her neck at Gloucestershire Royal hospital.
The assistant coroner for Gloucestershire, Roland Wooderson, said it was likely the tube became obstructed when her bed was rotated.
He said: “I find on balance of probabilities that the sudden catastrophic crisis faced by Jasmine was the obstruction of … the breathing system caused at the time of the rotation of the bed. I also find on balance of probabilities that such event more than minimally, negligibly or trivially contributed towards Jasmine’s death.”
The coroner said he accepted the evidence of an expert who said that there was “an opportunity for the wheels of the bed or any other equipment to roll over the breathing system tubing”.
In a statement released at the end of the inquest, Hill’s family said they hoped lessons would be learned. They said: “We’re grateful that the coroner uncovered what happened that day to our beloved Jasmine. She was a kind, creative and loving spirit who made such an impact on the lives of others.
“Jasmine was a timid, quiet and sometimes shy girl, and once you got to know her, she would open up, exposing her depth of character, sense of humour, intelligence, warmth and love.
“In our overwhelming grief, we have struggled to get answers from the hospital over the past two years and while it has been extremely hard to come to terms with what happened, we hope that the findings will contribute to preventing such a tragedy happening ever again.”
Gloucestershire coroner’s court heard the teenager, from Cirencester, had been readmitted to the hospital after her neck became swollen five days after undergoing a thyroidectomy – the removal of all or part of the thyroid gland – in September 2020.
Doctors thought the site of the surgery may have been infected and it was decided she needed to go to theatre to clean the wound under general anaesthetic.
The procedure took less than an hour but the teenager, who wanted to be a journalist or writer, went into cardiac arrest shortly after she was moved to a recovery bed.
A medic suggested she could have bitten on the tube as she coughed and began to wake up. But an expert witness, Prof Jonathan Hardman, said biting was unlikely because there was no evidence of damage to the tube.
He said: “We know that the bed was rotated 180 degrees. 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.
“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.”
The coroner, in his conclusions, said he accepted Hardman’s evidence “without reservation”.
Prof Mark Pietroni, the director of safety and medical director at Gloucestershire Hospitals NHS foundation trust, said: “We would like to extend our heartfelt sympathies to the family of Jasmine Hill for their tragic loss. We have only just received the coroner’s verdict. We will consider it carefully in order to understand its implications in detail.”