This video is a reconstruction of what happened when Mrs Elaine Bromiley, a healthy middle-aged lady, underwent routine ENT surgery. Unfortunately, the anaesthetists encountered unexpected difficulty in managing Elaine's airway. They were unable to intubate and a CICO situation developed. Despite years of experience, the anaesthetists persisted with multiple attempts at intubation instead of trying other options to oxygenate.

The video was created by Elaine's family and those involved to highlight some of the human factor issues that occur in these crisis situations. Watch the video and think about what human factors stopped those involved acting as they had been trained to.

Select Play to watch the video