On the 2nd April 2022, I commenced an investigation into the death of Jodie Catherine McCann. The investigation concluded at the end of the inquest on the 19th April 2023 The conclusion of the inquest was a Narrative as follows: Jodie died on the 2nd April 2022 at Queens Hospital, Burton-on-Trent, following a prolonged cardiac arrest, caused by a lack of oxygen, as the trachea could not be re-intubated following the sudden displacement of her tracheostomy tube. Jodie required the tracheostomy tube to provide ventilation to her lungs, as she had developed multi organ failure following an earlier cardiac arrest of at least 17 minutes at Kings Mill Hospital on 18.3.22. This first arrest at Kings Mill Hospital was sudden and unpredictable, likely caused by airway obstruction, from a combination of opiates affecting her breathing, her high BMI, and the pain and stress of gallstone pancreatitis which required strong opiate medication. Undertreated Hypothyroidism also likely made a more than minimal contribution to this first arrest. Jodie was making a reasonable recovery from the first arrest, with improving neurology and reducing ventilatory requirements. She was transferred to Burton Hospital on 22.3.22 for further critical care management. There she continued to improve, but required continuing ventilation. A tracheostomy tube to aid weaning from ventilation was inserted on 31.3.22. There was no individualised planning for the possibility of tracheostomy displacement , which was a known risk, with no plan to ensure the correct equipment was available, and no plan to ensure senior help was available as quickly as possible, should the tracheostomy tube become displaced. These serious issues of care at Burton Hospital, on a balance of probability, made a more than minimal contribution to Jodie’s death.

Jodie was a previously fit and well young woman aged twenty two. She developed gallstone pancreatitis requiring admission to Kings Mill Hospital on 16.3.22. She had a cardiac arrest on the ward at KMH on 18.3.22, and as a consequence developed multi organ failure, requiring Critical Care treatment. She had a period of care at KMH CCU, but had to be transferred to Burton Hospital on 22.3.22 as KMH CCU was at operational capacity.

She continued to make good progress on the CCU at Burton Hospital, but there were continuing issues of difficult airway management. Jodie had a tracheostomy tube placed on 31.3.22, which became displaced early morning on 2.4.22. This could not be replaced, nor another airway achieved. She died from a further prolonged cardiac arrest as a consequence of this final hypoxic event. The Determination dated 19.4.23 gives detailed findings as to the circumstances of Jodie’s death, and is appended to this report.

Jodie died on the 2nd April 2022 at Queens Hospital, Burton-on-Trent, following a prolonged cardiac arrest, caused by a lack of oxygen, as the trachea could not be re-intubated following the sudden displacement of her tracheostomy tube. Jodie required the tracheostomy tube to provide ventilation to her lungs, as she had developed multi organ failure following an earlier cardiac arrest of at least 17 minutes at Kings Mill Hospital on 18.3.22. This first arrest at Kings Mill Hospital was sudden and unpredictable, likely caused by airway obstruction, from a combination of opiates affecting her breathing, her high BMI, and the pain and stress of gallstone pancreatitis which required strong opiate medication. Undertreated Hypothyroidism also likely made a more than minimal contribution to this first arrest. Jodie was making a reasonable recovery from the first arrest, with improving neurology and reducing ventilatory requirements. She was transferred to Burton Hospital on 22.3.22 for further critical care management. There she continued to improve, but required continuing ventilation. A tracheostomy tube to aid weaning from ventilation was inserted on 31.3.22. There was no individualised planning for the possibility of tracheostomy displacement , which was a known risk, with no plan to ensure the correct equipment was available, and no plan to ensure senior help was available as quickly as possible, should the tracheostomy tube become displaced. These serious issues of care at Burton Hospital, on a balance of probability, made a more than minimal contribution to Jodie’s death.