He told me there was an instrument used called a Cook catheter, that no one was familiar with or trained in.
She said that the use of the Cook catheter to intubate Mr Ewing for surgery may also have contributed to his death as no one was actually trained to use it.
And consultant anaesthetist Deepa Singh decided to use a Cook catheter
to give him the gas, despite no one in the room being trained in its use.
When catheters remained in service for 11-30 additional days, the Cook catheter
exhibited better protection.