Elaine Bromiley Case

Elaine Bromiley was admitted to hospital for routine sinus surgery. During the anaesthetic Elaine experienced breathing difficulties, several unsuccessful attempts were made to secure Elaine’s airway.’ Elaine suffered brain damage and deteriorated over the next 13 days, never regaining consciousness.

Read this extract from the summary of the case [4]:

“The management of the ‘can’t intubate, can’t ventilate’ situation did not follow the accepted Difficult Airway Society guidelines.

In particular too much time was taken in trying to intubate the trachea rather than concentrating on ensuring adequate oxygenation by other means such as direct access to the trachea.

Whilst theatre staff ensured that all necessary equipment was available, the clinicians appeared to become oblivious to the passing of time and thus lost opportunities to limit the extent of damage caused by the prolonged period of hypoxia.

Given the skill mix of the clinicians, it would have been very easy to perform a surgical procedure to gain access to the trachea. Theatre staff, when interviewed, all seemed surprised that such was not performed.”

This report has been made available by the Bromiley family for the purpose of learning. The full report can be found here:  Elaine Bromiley case report

Many elements of the error chain have been directly identified in this case as Human Factors errors which are easily preventable.

Click here to view the video re-enactment of the real life clinical error.