Coroner rules hospital bed at fault for death of teenager
An inquest heard Jasmine Hill's oxygen tube was blocked as she was moved after an operation
Last updated 10th Nov 2022
An inquest heard that the teenager from Cirencester unexpectedly died after her oxygen tube was blocked as she was moved onto a hospital trolley during emergency surgery.
17-year-old Jasmine Hill suffered a fatal cardiac arrest shortly after undergoing a procedure on her neck at Gloucestershire Royal Hospital.
Miss Hill had been readmitted after a thyroidectomy left her with a red and swollen would that wasn't responding to antibiotics. When doctors were unable to relieve swelling, she was taken to the operating theatre at Gloucestershire Royal Hospital.
Assistant Coroner for Gloucestershire Roland Wooderson said the most likely cause of the breathing tube obstruction was when the teenager was moved from the operating table to a recovery bed.
Recording his findings following a three-day inquest, the coroner 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.
"I also find on balance of probabilities that such event more than minimally negligibly or trivially contributed towards Jasmine's death."
Trolley Wheel 'may have blocked oxygen tube'
The inquest was presented with data recovered from a surgical machine showing a 30 second gap in the supply of oxygen before Ms Hill went into cardiac arrest.
On the first day of the inquest a report conducted my Ms Hill's family lawyers stated the tube administrating the oxygen may have been trapped under a trolley wheel. But consultant anaesthetist, Dr Henry Murdoch, suggested Jasmine Hill could have bitten on the tube as she coughed and began to wake up.
The assumption was quashed by expert witness Professor Jonathan Hardman stating that if Jasmine Hill had bitten on her tube, marks would have been left. The lack of these, according to Professor Hardman, show this wasn't the case.
Adding to this, the expert witness and consultant anaesthetist said "In my opinion the most likely explanation for the sudden catastrophic event was an obstruction of the breathing line probably due to the rotating of the bed to aid the transfer."
Evidence had shown there was build-up of fluid in Jasmine Hill's lungs, which Professor Hardman said was "very unusual" for a young, fit and healthy person.
A post-mortem had failed to point out the cause of the teenager's death. In a statement Miss Hill family say they are relieved to finally have some answers, "We're grateful that the coroner uncovered what happened that day to our beloved Jasmine.
"She was a kind, creative and loving spirit who made such an impact on the lives of others.
"Jasmine 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.
"In our overwhelming grief, we have struggled to get answers from the hospital over the past two years and while it has been extremely hard to come to terms with what happened, we hope that the findings of this situation will contribute to preventing such a tragedy happening to any individual or family ever again."
The Family's solicitor, Sevim Ahmet, added that the family were now taking pursuing a civil claim.
Statement from Gloucestershire Hospitals NHS Trust
In response to the inquest's findings Gloucestershire Hospital NHS Trust's Director of Safety and Medical Director, Professor Mark Pietroni, says “We would like to extend our heart-felt 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.”