Trust accepts partial blame for teenager's death from blocked breathing tube | Fieldfisher
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Case Study

Trust accepts partial blame for teenager's death from blocked breathing tube

Sarah Kingsley Fried and Sevim Ahmet acted for the family of a teenage girl who died at Gloucestershire Royal Hospital due to a tragic error involving an anaesthetic breathing tube. The inquest was widely reported in local and national news.

Seventeen-year-old Rachel* was a bright and affectionate young woman from a tight-knit family. Despite health struggles, she was excelling at college, seeking part-time work, and hoping to go on university.  

Rachel suffered from Graves' disease, an autoimmune disorder resulting in the overproduction of thyroid hormones (hyperthyroidism). She underwent surgery at Gloucestershire Royal Hospital to remove her thyroid and although the surgery was a success, once home she developed painful swelling in her neck. Her mother took her back to hospital, where she underwent emergency surgery to drain the pooling blood (haematoma). 

After the surgery, Rachel remained under anaesthetic and was transferred from the operating table to a portable hospital bed. As this happened, and the bed was rotated, Rachel's oxygen saturation plummeted. 

Theatre staff attempted alternative methods of ventilation and commenced CPR. The consultant anaesthetist and surgeon were called urgently back to theatre. Rachel's oxygen continued to fall. Various investigations were attempted, but no cause was found for Rachel's sudden deterioration. After over an hour of attempted resuscitation a unanimous decision was made to stop intervention. Post-mortem examination provided no clear cause of death. 

Rachel's family instructed Fieldfisher to investigate her treatment. Expert evidence was obtained from an eminent anaesthetist, who concluded that the most likley cause of Rachel's death was physical obstruction of the breathing tube from the anaesthetic machine, which resulted in negative pressure pulmonary oedema. He suggested that a trailing anaesthetic tube may have been crushed by a wheel of the bed as it was rotated. 

On this basis, we sent a Letter of Claim to Gloucestershire Hospitals NHS Foundation Trust, the body responsible for Gloucestershire Royal Hospital. 

Meanwhile, an inquest was held at Gloucestershire Coroner's Court.   

Given the complexity of the evidence, the Coroner instructed his own expert anaesthetist and following correspondence on the medical evidence, this expert eventually reached the same conclusion as our own.

Leading up to the inquest, crucial further evidence was disclosed by Gloucestershire Hospitals NHS Foundation Trust, namely: 

  • Detailed technical data on the functioning of the anaesthetic machine (from a USB stick found by an anaesthetic machine technician)
  • An audio recording of discussions between the surgical and theatre teams immediately following Rachel's death (from the personal mobile of the anonymous staff member who had secretly recorded the conversation.)

Fieldfisher instructed Michael Deacon of 1 Crown Office Row to represent the family at inquest. Following the three-day hearing, the Coroner concluded that Rachel died as a result of an obstruction of her breathing tube, likley caused by the rotation of the bed.    

Some months after the inquest, the Trust provided a partial admission. No admission was made in relation to the cause of the obstruction, but it was accepted that there was delay in identifying and rectifying it.

In valuing the claim, Sarah and Sevim worked closely with the family to show the significant financial impact of Rachel's death, particularly the loss of support she would have been expected to provide to her mother as she got older. 

Factual evidence on the academic and professional achievements of Rachel and her sisters, was used to support a financial dependency claim for their mother.  

Following settlement, the family said:

'Fieldfisher were exceptional advocates when representing our family, who had little previous knowledge and engagement with the legal world, and supported us throughout a complex and challenging medical negligence case against an NHS Trust. From the outset, Fieldfisher demonstrated dedication and professionalism and was vital in ensuring that we achieved justice on behalf of my late sister.

I am 100% sure that we would not have achieved the justice we were looking for had Fieldfisher not been involved. The answers and outcome that Fieldfisher obtained on our behalf mean that our family can begin to gain a sense of closure. 

I’d recommend Fieldfisher for their unmatched expertise, compassionate approach, and commitment to achieving the best possible outcome for their clients. Their willingness to take on our case on a ‘no win, no fee arrangement’ made all the difference for us as a low-income family, allowing us to pursue justice without the financial burden. 

We are deeply grateful for their support and guidance during such a difficult time.'

About Sarah:

'Sarah was instrumental in navigating our case. With her extensive experience and expertise in medical negligence law, Sarah instilled in us the confidence we desperately needed during an incredibly challenging time. Sarah's dedication to our case exceeded all expectations. She handled every aspect to the highest standard, ensuring transparent communication and meeting all deadlines with precision. 

Sarah's empathetic and compassionate approach alongside her genuine care for our well-being was evident throughout our interactions. Her professionalism and dedication exemplify the high standards set by Fieldfisher. Sarah's presence throughout the case, particularly through the inquest proceedings, provided reassurance and she always ensured any questions or queries were answered swiftly. We cannot thank Sarah and the team enough for her tireless efforts and outstanding support - she is an asset to Fieldfisher.'

About Sevim:

From our initial consultation, Sevim provided us with honest and transparent advice and provided a clear picture of what was required to take forward our case. 

Her expertise and professionalism were evident throughout - especially during inquest proceedings, where she represented us to the media with integrity and diligence. Sevim's strategic approach and attention to detail were invaluable. Beyond her legal realm, Sevim exhibited genuine compassion and empathy. We are immensely grateful for Sevim's dedication to our case and the outstanding service provided by Fieldfisher.'

Contact us

For further information about hospital negligence claims and medical negligence claims, please call Sarah Kingsley Fried on 0330 460 6815 or email or contact Sevim Ahmet on 03304606816 or email


All enquiries are completely free of charge and we will investigate all funding options for you including no win, no fee.

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Medical Negligence Claims