Authors: Matt Bigwood, ST6 Anaesthesia, University Hospitals of Leicester and Chris Frerk, Consultant Anaesthetist, Northampton General Hospital.

The Royal College of Anaesthetists is launching a campaign to prevent future deaths from unrecognised oesophageal intubation following a recently received coroner’s report where an oesophageal intubation took place and was not recognised in time to save the life of the patient. The coroner’s report highlighted the critical importance of human factors in safe anaesthetic practice.

Chris Frerk is the chair of the patient safety charity, the Clinical Human Factors Group. He has been teaching healthcare workers about speaking up over the last 10 years and Matt Bigwood is an Airway and Obstetric Fellow. Spreading the Freedom to Speak Up message through education and practice.


Glenda Logsdail died because of a medical error. A breathing tube was placed in her stomach when it should have been in her lungs.

She rapidly turned blue from lack of oxygen, and it was clear to everyone that something was seriously wrong. The doctor in charge knew it was an emergency situation, but he diagnosed the wrong emergency. He believed that he was seeing a life-threatening allergic reaction to one of the medicines that had just been given. The team kept treating Glenda for an allergy until it was too late.

The coroner identified several things that might have stopped staff speaking up. These included problems with hierarchy, leadership, and teamwork.

Getting hierarchy right is difficult in any industry. Too steep and workers may be afraid to speak up; too shallow and leadership can be lost, and teamwork suffers. A good leader doesn’t need a large power imbalance to lead effectively.  A popular initiative to try to reduce hierarchy is to use first names during team conversations rather than titles and surnames. In a crisis, like Glenda’s, team members need to be able to:

  • Identify the problem
  • Speak up
  • Be heard and
  • Be listened to.

All these skills take practice.

Identifying the problem is the first essential step. In Glenda’s case, this could have been identified with the monitor used during every anaesthetic that can detect whether the breathing tube is in the right place. When in the lungs a “trace” shows each breath on the monitor. When in the stomach the monitor shows a flat line, and the problem can be quickly corrected with no harm to the patient.

The Royal College of Anaesthetists have relaunched a campaign to raise awareness of this called “No Trace = Wrong Place”. One of the main aims of the campaign is to empower every team member, regardless of position, to be able to speak up if they spot this problem.

We have made considerable progress  encouraging and enabling people to speak up in healthcare. Where hierarchy is still a problem, we can teach people to use specific language which makes speaking up feel easier. This starts with, ”I am concerned”, and moves on to, “I am uncomfortable”. If these two challenges don’t have the desired effect, they can use the phrase “this feels unsafe”.

In some previous similar cases, team members have identified the problem, and have “spoken up”. However, sometimes they were not heard, or their suggestions were dismissed. There is a fine balance between decisiveness in a leader (which is desirable) and too high a level of certainty that inhibits challenge from the team.

In the aviation industry, teams are taught specifically how to speak up and how to listen up. They are also trained to ask for help using open questions. We must learn from them and shift the attitude of our leaders to be able to ask their teams for contributions and have an open mind to accepting different ideas. One way of encouraging this is using “crisis simulation training”. This allows the whole team to practice all these different skills in a safe environment. This will help reduce the risk of failures of leadership and teamwork.

For anaesthetists, a method to reduce the chance of a similar tragedy happening again would be to require a second person to confirm the breathing tube position as part of a routine double check. The leader would expect their trained assistant to speak up every time they place a breathing tube. The assistant would confirm whether they had seen the trace on the monitor or not. Similar two-person checks are already used widely in health and other sectors and have been shown to reduce errors.

There are many things we need to learn from Glenda’s case, one of which is about the importance of speaking up. Practice in having difficult conversations will lead to better teamwork and better leadership. This will save lives.