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| Hospital trolley probably caused teenager's death, coroner says | Hospital trolley probably caused teenager's death, coroner says |
| (25 days later) | |
| Jasmine Hill's family said she was "a kind, creative and loving spirit" | Jasmine Hill's family said she was "a kind, creative and loving spirit" |
| A 17-year-old most likely died during emergency treatment after her oxygen tube was blocked as she was moved on to a hospital trolley, a coroner ruled. | A 17-year-old most likely died during emergency treatment after her oxygen tube was blocked as she was moved on to a hospital trolley, a coroner ruled. |
| Jasmine Hill, from Cirencester, suffered a fatal cardiac arrest shortly after undergoing a procedure on her neck at Gloucestershire Royal Hospital. | Jasmine Hill, from Cirencester, suffered a fatal cardiac arrest shortly after undergoing a procedure on her neck at Gloucestershire Royal Hospital. |
| Assistant Coroner for Gloucestershire Roland Wooderson said his verdict was based on "a balance of probabilities". | Assistant Coroner for Gloucestershire Roland Wooderson said his verdict was based on "a balance of probabilities". |
| In a tribute Miss Hill was described as "a kind, creative and loving spirit". | In a tribute Miss Hill was described as "a kind, creative and loving spirit". |
| The three-day inquest at Gloucestershire Coroner's Court heard that Miss Hill had undergone thyroid surgery in September 2020 but developed a possible infection and had been re-admitted to the hospital. | The three-day inquest at Gloucestershire Coroner's Court heard that Miss Hill had undergone thyroid surgery in September 2020 but developed a possible infection and had been re-admitted to the hospital. |
| It was decided Miss Hill needed to go to theatre to clean the wound under general anaesthetic. | It was decided Miss Hill needed to go to theatre to clean the wound under general anaesthetic. |
| It was as she was coming round from this second procedure she suffered a catastrophic lack of oxygen. | It was as she was coming round from this second procedure she suffered a catastrophic lack of oxygen. |
| Data from a surgical machine showed there was a 30-second break in the administration of oxygen to Miss Hill. | Data from a surgical machine showed there was a 30-second break in the administration of oxygen to Miss Hill. |
| Miss Hill, 17, died in September 2020 | Miss Hill, 17, died in September 2020 |
| Mr Wooderson ruled that the most likely cause of the breathing tube obstruction was when the teenager was moved from the operating table to a recovery bed. | Mr Wooderson ruled that the most likely cause of the breathing tube obstruction was when the teenager was moved from the operating table to a recovery bed. |
| "I find on balance of probabilities that the sudden catastrophic crisis faced by Jasmine was the obstruction of the inspiratory limb of the breathing system caused at the time of the rotation of the bed," he said. | "I find on balance of probabilities that the sudden catastrophic crisis faced by Jasmine was the obstruction of the inspiratory limb of the breathing system caused at the time of the rotation of the bed," he said. |
| The inquest heard how Miss Hill's family believe the tube had been squashed by the wheel of the trolley. | The inquest heard how Miss Hill's family believe the tube had been squashed by the wheel of the trolley. |
| It was also suggested she could have bitten on the tube as she coughed and began to wake up. | It was also suggested she could have bitten on the tube as she coughed and began to wake up. |
| But expert witness, Prof Jonathan Hardman, said biting was unlikely as a cause because there was no evidence of damage to the tube. | But expert witness, Prof Jonathan Hardman, said biting was unlikely as a cause because there was no evidence of damage to the tube. |
| Giving evidence, the consultant anaesthetist said "the most likely explanation" was "an obstruction of the breathing line probably due to the rotating of the bed to aid the transfer". | Giving evidence, the consultant anaesthetist said "the most likely explanation" was "an obstruction of the breathing line probably due to the rotating of the bed to aid the transfer". |
| "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," he said. | "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," he said. |
| A post-mortem examination was unable to establish the cause of the teenager's death. | A post-mortem examination was unable to establish the cause of the teenager's death. |
| Miss Hill suffered a cardiac arrest at Gloucestershire Royal Hospital | Miss Hill suffered a cardiac arrest at Gloucestershire Royal Hospital |
| In his conclusions, Mr Wooderson said he accepted Prof Hardman's evidence and conclusions "without reservation". | In his conclusions, Mr Wooderson said he accepted Prof Hardman's evidence and conclusions "without reservation". |
| Recording a narrative conclusion, he added: "She died as a result of complications arising during a routine operation. | Recording a narrative conclusion, he added: "She died as a result of complications arising during a routine operation. |
| "There was an obstruction in the tube leading from the hospital ventilation equipment to her endotracheal tube which compromised her ability to be oxygenated and which triggered severe pulmonary edema." | "There was an obstruction in the tube leading from the hospital ventilation equipment to her endotracheal tube which compromised her ability to be oxygenated and which triggered severe pulmonary edema." |
| In a statement released at the end of the inquest, Miss Hill's family said: "We're grateful that the coroner uncovered what happened that day to our beloved Jasmine. | In a statement released at the end of the inquest, Miss Hill's family said: "We're grateful that the coroner uncovered what happened that day to our beloved Jasmine. |
| "She 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. | "She 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. |
| "We hope that the findings of this situation will contribute to preventing such a tragedy happening to any individual or family ever again." | "We hope that the findings of this situation will contribute to preventing such a tragedy happening to any individual or family ever again." |
| Professor Mark Pietroni, 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 Jade Hill for their tragic loss. | Professor Mark Pietroni, 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 Jade 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." | "We have only just received the coroner's verdict. We will consider it carefully in order to understand its implications in detail." |
| Solicitor Sevim Ahmet, from Fieldfisher who represented the family, added: "Finding the answers as to how Jasmine died was made more difficult by the trust's conduct in disclosing evidence late and omitting key information from the records provided to the coroner's expert. | Solicitor Sevim Ahmet, from Fieldfisher who represented the family, added: "Finding the answers as to how Jasmine died was made more difficult by the trust's conduct in disclosing evidence late and omitting key information from the records provided to the coroner's expert. |
| "Without our medical expert highlighting the likely cause, Jasmine's family would still be in the dark. | "Without our medical expert highlighting the likely cause, Jasmine's family would still be in the dark. |
| "What is now clear is that Jasmine's death was avoidable and I know her family will take some small relief if new safety recommendations around anaesthesiology result so that other families do not suffer similar devastation." | "What is now clear is that Jasmine's death was avoidable and I know her family will take some small relief if new safety recommendations around anaesthesiology result so that other families do not suffer similar devastation." |
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