Despite the Royal College of Anaesthetists (RCA) specifically issuing a training video around the No Trace=Wrong Place campaign in 2019, Ms Currell died a year later when a breathing tube was inserted into her oesophagus rather than her trachea, causing fatal cardiac arrest.
Ms Currell was attending regular dialysis for ongoing kidney problems when she suffered a fit on her way home. She was admitted to A&E at Watford General hospital. Clinicians treating Ms Currell did not appear to be aware of the campaign prior to her death.
Following a very critical internal investigation, the hospital trust promised the coroner that an overhaul of procedures had taken place to prevent similar tragedy happening again. The coroner heard that despite two doctors raising concerns about the placement of the tube, the lack of a carbon dioxide trace, which indicates the person is not breathing, was assumed to be the fault of an unreliable monitor.
Speaking to ITV News after the inquest, Emma Kendall argued that the RCA could do more to broadcast the training at national and local level. She also raised the possibility of reinstating oesophageal intubation onto the NHS Never Events list.
Read the BBC's coverage of the inquest.
Partner Kate Rohde currently represents the family of Glenda Logsdail who also died following oesophageal intubation. Read more about the case.
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