Litigation related to airway and respiratory complications of anaesthesia: an analysis of claims against the NHS in England 1995–2007

Abstract

Summary Claims notified to the NHS Litigation Authority in England between 1995 and 2007 and filed under anaesthesia were analysed to explore patterns of injury and cost related to airway or respiratory events. Of 841 interpretable claims the final dataset contained 96 claims of dental damage, 67 airway‐related claims and 24 respiratory claims. Claims of dental damage contributed a numerically important (11%), but financially modest (0.5%) proportion of claims. These claims predominantly described injury during tracheal intubation or extubation; a minority associated with electroconvulsive therapy led to substantial cost per claim. The total cost of (non‐dental) airway claims was £4.9 million (84% closed, median cost £30 000) and that of respiratory claims was £3.3 million (81% closed, median £27 000). Airway and respiratory claims account for 12% of anaesthesia‐related claims, 53% of deaths, 27% of cost and ten of the 50 most expensive claims in the dataset. Airway claims most frequently described events at induction of anaesthesia, involved airway management with a tracheal tube and typically led to hypoxia and patient death or brain injury. Airway trauma accounted for one third of airway claims and these included deaths from mediastinal injury at intubation. Pulmonary aspiration and tube misplacement, including oesophageal intubation, led to several claims. Among respiratory claims, ventilation problems, combined with hypoxia, were an important source of claims. Although limited clinical details hamper analysis, the data suggest that most airway and respiratory‐related claims arise from sentinel events. The absence of clinical detail and denominators limit opportunities to learn from such events; much more could be learnt from a closed claim or sentinel event analysis scheme.

Complications of Airway ManagementDiscussion

“…According to a closed-claims analysis by Domino et al 2 6% of claims against anesthesiology providers were for airway injury, with the larynx being the most common site of injury, followed by the pharynx and the esophagus. Data from England documented by Cook et al 3 demonstrate a similar percentage of claims related to airway management (8%). Beyond medicolegal issues, intubation-related injury is also a significant financial burden.…”

Education in airway management

“…In a review of litigation related to anaesthesia in National Health Service (NHS) hospitals in the UK from 1995 to 2007, airway and respiratory related events accounted for 12% of all anaesthesia claims, 53% of deaths and 27% of cost, and were involved in 10 out of the 50 most expensive claims [2].…”

Hypoxia: developments in basic science, physiology and clinical studies

“…The resulting sensations can be very distressing for patients and lead to a vicious cycle of dyspnoea, increased oxygen consumption, but (because of upper airway collapse) inspiratory flow limitation. Furthermore, aspiration can occur: the Fourth National Audit Project of the Royal College of Anaesthesists and Difficult Airway Society (NAP4) in the UK has shown that overall, this was a leading cause of hypoxia causing anaesthesia-related mortality [2][3][4].…”

“…The first 72 h after surgery is a period of high risk (one in three cases in NAP4 occurred at emergency or recovery [2][3][4]). A prospective survey of > 18 000 patients in the post-anaesthesia care unit revealed a complication rate of 7% related to airway obstruction [42].…”

“…For each of these, the primary purpose of airway management is the avoidance of hypoxia, yet hypoxia and hypoxia-related injury remain among the main ultimate causes of anaesthetic-related death and serious morbidity [1][2][3][4]. While much progress has been made in techniques and tools to establish an appropriate airway for a procedure, two other areas of considerable research interest are related to the physiological response to hypoxia.…”