The SALG Patient Safety Updates contain important learning from incidents reported to the Learning From Patient Safety Events (LFPSE) system. The RCoA and the Association aim to bring these Safety Updates to the attention of as many anaesthetists and their teams as possible. The updates are published every four months and contain data from an earlier time period.

Paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009 requires coroners to issue reports to individuals, organisations, local authorities, or government bodies when they believe action is needed to prevent future deaths.

When such a report is received by the Royal College of Anaesthetists or the Association of Anaesthetists, SALG (Safe Anaesthesia Liaison Group) generates a response and oversees implementation of any recommended actions.

This update outlines actions taken based on SALG’s response to a coroner regarding the sad death of Mr Maxwell Frame, which raised concerns about the lack of a national policy on central venous catheter (CVC) placement. The original report and SALG’s response are available on the SALG website.

In its response, SALG noted that the Association of Anaesthetists’ guidance on ‘Safe Vascular Access’ was being updated to include clearer recommendations on CVC placement. The revised guidance was published last month in Anaesthesia.

Additionally, FICM and ICS have updated their Central Venous Catheter Insertion checklist, which can be used by organisations as the basis for their LocSSIP. This checklist is available on the FICM website.

SALG was asked to justify  support for the removal of postoperative pain as an indication for modified-release opioids, based on the Public Assessment Report published in March 2025, and highlighted in the previous edition of the  Patient Safety Update (published May 2025). The correspondent requested evidence of patient harm when modified release opioid medications were used in enhanced recovery protocols following arthroplasty and caesarean section.

This case was reported directly to SALG by the anaesthetist involved in the case

An elderly patient was referred for HoLEP. Apart from hypertension [the patient] was in reasonable health with a starting Hb of 14g/dl. [The patient] received sevoflurane/ N₂O based general anaesthesia, the trachea was intubated and an arterial line sited. The resection lasted approximately 3hrs. 365g of tissue was resected and blood loss was unremarkable. Approximately 200L of 0.9% saline was used for irrigation. The patient remained cardioivascularly stable throughout apart from an episode towards the end of the case. Prominent scleral oedema noticed. There was no significant hypoxia.

Arterial Blood Gas (ABG) taken once resection complete revealed a Hb 7, Cl 117 with a mild acidaemia. 2 units packed red cells were infused. Frusemide 40mg given intravenously as it was considered that excess fluid absorption was likely.

The patient was confused at the time of extubation but settled after 30mins, on arrival in post-operative recovery they reported some hearing loss in the right ear which persisted to discharge. ENT follow-up identified impaired hearing that was considered likely to be permanent.

This incident was reported to SALG and subsequently escalated for review by NHS England

An oesophageal temperature probe that was being used during upper GI surgery, migrated intraoperatively into the stomach and was inadvertently trapped in a staple line/anastomosis. There were no device issues, however there were also no alarms or disruption in monitoring to make the team aware of the issue.

This content has been generated for SALG by the anaesthetist involved in the case, with editorial assistance from Dr Sandeep Sudan on behalf of the Difficult Airway Society

A patient of BMI 40+ underwent surgical tracheostomy to facilitate weaning from mechanical ventilation. On the third day after tracheostomy, the patient suffered a cardiac arrest due to suspected obstruction of the tracheostomy tube. The tracheostomy tube was removed, and the trachea reintubated via the oral route using a video laryngoscope and bougie. A sustained, square-wave end tidal carbon dioxide trace was obtained, followed by return of spontaneous circulation. As there was a large leak of air from the tracheostoma, the endotracheal tube tip was presumed to be lying above this section of the trachea, so was advanced further in line with NTSP guidance.^]

Shortly after advancing the endotracheal tube, subcutaneous emphysema of the chest and neck developed and the patient sustained a further cardiac arrest. An attenuated, intermittent, CO2 trace was present during this time, which was interpreted as indicating an appropriate position of the endotracheal tube in the context of an ongoing cardiac arrest. Tension pneumothorax was postulated as a cause for the second arrest and bilateral needle decompressions were undertaken, without improvement in the patient’s condition.

Subsequent flexible endoscopic examination via the endotracheal tube failed to reveal tracheobronchial anatomy. The tracheostoma was explored at the bedside by an ENT surgeon who found that the oral endotracheal tube had exited the trachea, via the tracheostoma, into the adjacent soft tissues of the neck – a finding that was not evident on external examination due to the raised BMI. The endotracheal tube was removed from the mouth and an Igel placed, with reoxygenation, sustained ETCO2 and return of circulation occurring shortly afterwards.

Following discharge after an uneventful surgical procedure, a patient contacted the hospital reporting an episode of accidental awareness during general anaesthesia. The anaesthetist and the ODP identified that the vaporiser although turned on, was empty. An episode of tachycardia had alerted the anaesthetic team and the error was identified and rectified perioperatively.

This content has been generated for SALG by Dr Sandeep Sudan on behalf of the Difficult Airway Society

CASE 1

A patient presented to Accident and Emergency with a post operative bleed 3 days after a hemithyroidectomy. Nasendoscopy showed a patent upper airway. The senior anaesthetic resident discussed the case with their consultant. The patient’s airway assessment was favourable (MP1) and they agreed that the resident would use videolaryngoscopy for intubation, using a supraglottic airway as Plan B, with fibreoptic available. The consultant surgeon was also happy to let their registrar continue in their absence.

The resident was unable to intubate or ventilate through a SGA. Both the resident and an on-site ITU consultant were unable to get emergency front of neck access [eFONA] via the open neck wound. After a second failed attempt at eFONA the ICU consultant managed to intubate orally using laryngoscopy and a bougie passed blindly.

The patient was swiftly re-oxygenated and vital signs returned to acceptable levels (5 mins of inability to ventilate, sats dropped to 11%) There was no cardiac arrest.

After a suitable period of stability, the patient was moved to the operating theatre and surgery took place.

CASE 2

A surgical tracheostomy was performed (adjustable flange) on an ITU patient. Back in ITU a post operative chest x-ray showed the tip of tube to be at the carina. When the flange of tracheostomy was withdrawn 2 cm, ventilation became impossible and could not be restored when the tube was returned to its original position.

The inner cannula was removed but a suction catheter could not be passed, the patient still could not be ventilated and the oxygen saturations dropped to 40%. Bronchoscopy via the tracheostomy showed the tube against tracheal wall but attempts to reposition it in the trachea caused further desaturation. The ICU consultant inserted a bougie and tube orally using a videolaryngoscope but could not pass either beyond the vocal cords, even after the tracheostomy tube was removed.

Another trial of intubation which was unsuccessful, and ventilation was impossible with either a 2^nd gen supraglottic airway or a face mask. Jet ventilation via a cannula through the tracheostomy stoma also failed. The duty anaesthetist from theatres was called. In total the patient experienced around 10 minutes with minimal or no ventilation. There was loss of cardiac output and chest compressions were started. After several further attempts the trachea was intubated with a size 8 tube using a videolaryngoscope.  The patient received 14 minutes CPR before return of spontaneous circulation.

CASE 3

A frail patient with small bowel obstruction required emergency laparotomy. Previous difficult intubation was noted, and it was decided to induce anaesthesia in theatre preoxygenated. Plan for RSI: Mac-VL, bougie, cricoid. After careful positioning the patient was pre-oxygenated. First attempt at laryngoscopy was by the resident anaesthetist who found copious gastric contents obscuring the view; the airway was suctioned and the patient positioned head down. During a second attempt at laryngoscopy further copious gastric secretions were suctioned. SpO2 started to decline slowly (92%). The consultant inserted an igel to restore oxygenation with good effect. Assistance was requested from second consultant anaesthetist and ENT consultant in adjacent theatre. The trachea was intubated with Mac –VL and stylet. The ENT consultant performed immediate bronchoscopy and lavage. However, oxygenation became increasingly challenging despite recruitment manoeuvres. CXR showed a collapsed right upper lobe. The ICU consultant performed repeat bronchoscopy and lavage with some improvement in oxygenation.

This content has been generated for SALG by Dr Scott Grier, Clinical Director, Retrieve Adult Critical Care Transfer Service and chair of the working party updating the ICS guidance on transfer of the critically ill adult.

A cardiac patient required transfer from one hospital to another. Upon arrival of the ambulance, there were delays both in locating the patient, and identifying which staff were to accompany the patient. The crew were waiting for over 30 mins while wider team decided. The doctor accompanying the patient did not have an assistant with them. It was unclear if the hospital staff were aware of the crew’s SOPs for the type of transfer.

The crew- assisted by nursing staff- transferred the patient onto the ambulance trolley. There was then a further 30-minute delay establishing IABP monitoring.

Multiple road closures near the destination caused a delay of approximately 5 minutes on normal journey time. The doctor accompanying the patient did not seem to be aware of the process for handover of the patient at the receiving hospital. Once inside the hospital, after handover to the appropriate hospital staff the patient suffered a cardiac arrest.

This content has been generated for SALG by Dr Amy Dodd and Dr Linda Nel on behalf of the Perioperative Allergy Network

A patient was given an epidural infusion of bupivacaine for analgesia following elective abdominoplasty. During the morning ward round, the sensory block was noted to be at T4. During the course of the day, the bupivacaine infusion was titrated according to block, based on the telephoned instructions of the ICU Consultant. At the evening nurse handover, it was noted that the patient was increasingly bradycardic. During assessment - by the only doctor on the unit- the patient became unresponsive, with an audibly obstructed airway.  They were profoundly hypotensive with flattened arterial and ECG traces. Extra nursing staff were called over and the ICU consultant was contacted. Following administration of atropine the heart rate immediately increased to 66 but the BP remained labile. The epidural infusion was stopped. At the time the sensory block was noted to be at T4. A jaw thrust was used to establish a patient airway and oxygen 15L/min administered via a waters circuit. On arrival of the consultant a noradrenaline infusion was requested.

CASE 1

A patient suffered cardiac arrest in theatre due to hyperkalaemia and it was noted that the patient was known to be a haemodialysis patient. Bloods were not checked immediately pre-theatre.

CASE 2

Dialysis patient was admitted for cataract surgery which was performed under general anaesthesia (GA). No blood tests taken post op. Patient discharged and readmitted later that day with life-threatening hyperkalaemia of 8.8, likely due to GA requiring ITU admission for continuous veno-venous haemofiltration (CVVH).

A patient underwent a haemorrhoidectomy procedure under general anaesthesia, receiving atracurium prior to intubation.  At the end of the procedure, the patient was breathing spontaneously and had 2 twitches measured using a qualitative peripheral nerve stimulator.  Neostigmine/glycopyrrolate was given and the patient was extubated 5 minutes later when they responded to verbal command.  The patient was placed in a sitting position on the trolley and noted to have a lot of secretions in their airway.  The patient appeared to be stable, so the anaesthetist turned their attention away momentarily and turned back to the deteriorating patient who rapidly became cyanosed despite being on supplemental oxygen, developing a severe bradycardia that was unresponsive to atropine and progressed to asystole.  A cardiac arrest was declared and cardiopulmonary resuscitation commenced.  Return of spontaneous circulation occurred after re-intubation and the patient was transferred to the intensive care unit for post-resuscitation care.

A critically unwell patient was transferred from ICU to theatre for emergency laparotomy. They had already been intubated and an arterial line sited. Due to urgency of the procedure, the anaesthetic team, including a consultant, made the decision to allow the operation to start with 22G and 18G cannulae for access and site a central line during the procedure. On opening the abdomen, the patient had a cardiac arrest. CPR commenced. 2x ICU consultants attended. EZ-IO sited to aid access but all drugs given via peripheral cannula. Chest compressions made it difficult to site a central line but the left internal jugular was eventually cannulated. The results from bloods sent including venous blood gas, were incompatible with life. CPR stopped after 25 minutes after discussion with multidisciplinary team.

The Anaesthetic resident was called to the Coronary Care Unit (CCU) for a patient with cardiogenic shock receiving continuous positive airway pressure (CPAP) and metaraminol infusion initiated overnight.  Electrocardiograms were highly suggestive of left main stem coronary artery disease.  The patient required urgent intubation and transfer to the cardiac catheter lab for percutaneous coronary intervention.  The cardiac catheter lab was put on hold whilst waiting for the patient to be intubated.

This content has been reviewed for SALG by Dr Alistair Baxter and Dr Mark Barley on behalf of The Society for Intravenous Anaesthesia

A patient was transferred from [Hospital 1] to [Hospital 2] for an emergency interventional radiology procedure. The patient was intubated prior to transfer and sedated with a propofol infusion. They were received by anaesthetic consultant and ODP, transferred to an anaesthetic machine and moved to an interventional radiology table. Whilst monitoring was being transferred from transfer monitoring, it was noted that the transfer propofol infusion pump had been switched to a TCI pump by [Hospital 2] team. Asked to confirm what infusion rate of 1% propofol was running (was at 15ml/hr during transfer), it transpired that the patient had commenced propofol TCI and had been given an induction dose of propofol (rate of propofol being administered was 126ml/hr) - unclear amount but possibly would have been between roughly between ??60-100mg taking into account amount remaining in syringe and estimated amount used on transfer. Propofol infusion immediately stopped. No blood pressure reading as local intra-arterial blood pressure monitor was not set up yet at this stage. No palpable carotid/femoral pulse was felt. CPR commenced - brief (<1 min of CPR) until central pulse felt again, and then improved with metaraminol administration. Once IBP trace back, SBP 70 on metaraminol infusion 20ml/hr and with subsequent improvement.

An elderly patient underwent general anaesthesia for endoscopic retrograde cholangiopancreatography (ERCP). About 30 minutes into surgery, it was noted that the ventilatory parameters were showing reduced tidal volume [245-390ml] compared to the setting of 475ml tidal volume with increased airway pressure of 32cm H2O. This was attributed to endotracheal tube compression by the endoscope manipulation by the surgeon. As a result of this, the endotracheal tube position was re-adjusted with transient resolution of the problem.

A few minutes later, the same episode recurred and a gurgling sound was heard around the oro-pharynx. This was attributed to partial dislodgement of the endotracheal tube and onset of oxygen desaturation on the monitor. As a result of this, it was decided that surgery should stop and the trachea was rapidly re-intubated uneventfully. It was after this that it was noticed that the patient had suffered a ventricular fibrillation cardiac arrest and cardio-pulmonary resuscitation (CPR) was commenced immediately with chest compression and ventilation without interruption with the cardiac arrest team joining in the CPR. As soon as the crash trolley was brought in a DC shock with 150J was delivered. After two cycles, there was a return of spontaneous circulation for less than 2 minutes followed by a PEA arrest with recommencement of CPR including administration of Intravenous Adrenaline x 6 doses [total dose]. CPR continued for over 30 minutes with no return of spontaneous circulation. It was at this point that the team agreed to discontinue CPR and patient was pronounced  dead.