A baby was born at 41 weeks of gestation with no spontaneous respirations. There was a significant delay in intubation even once a lack of respiratory drive was recognised. Once the decision was made to intubate, the endotracheal tube, when inserted, was too far in (10 cm) and this then slipped to 12 cm. This is likely to have contributed to the development of a right-sided pneumothorax. In addition, there was a delay in inserting a chest drain when it was recognised as tension pneumothorax. The baby passed away at approximately 12 hours old.
As this example clearly demonstrates, issues related to intubation were an emerging theme where improvements could be made. Misplaced endotracheal (ET) tubes and a lack of end-tidal CO2 monitoring were common examples.