Tracheostomy care remains a vital yet complex component of modern healthcare, requiring seamless collaboration between multidisciplinary teams to ensure patient safety. Failures in education, procedural consistency, and communication continue to contribute to preventable morbidity and mortality. This national observational study analyses Prevention of Future Deaths (PFD) reports related to tracheostomy management in England and Wales, with the aim of identifying recurrent themes and informing policy and training interventions to enhance public health outcomes.

A systematic review of the UK judiciary PFD database identified 21 tracheostomy-related cases from July 2013 to the present. The total estimated loss-of-life cost from these preventable incidents was £54.9 million, reflecting the significant societal and economic burden of avoidable airway-related deaths. Each report was reviewed for patient demographics, contributing factors, and organisational responses, alongside compliance with statutory 56-day response requirements. Of these, 85.7% received published responses, with 25 organisations formally notified to implement safety measures. Patients ranged in age from infancy to the 80s. Recurrent themes included dislodged tracheostomies, failure to follow established protocols, omission of pre-procedure ultrasound to aid surgical planning, and delayed recognition of tube blockage.

The findings underscore the importance of evidence-based education, system-wide learning, and multidisciplinary training to reduce preventable deaths. Embedding structured tracheostomy management programmes within healthcare systems, supported by robust policy and communication frameworks, is crucial to improving outcomes and advancing public health.

This study provides actionable insights to strengthen airway safety across healthcare settings and to guide preventive strategies at both institutional and national levels.

Antoni Gardener completed a Bachelor of Science in Biochemistry at University College London in 2016 before studying Medicine at Pembroke College, University of Oxford. Following graduation, he undertook postgraduate medical and surgical training across the UK, including Oxford, the Isle of Wight, Kent, Surrey, London, and New Zealand. He successfully completed the MRCS (ENT) examination through the Royal College of Surgeons of Edinburgh and currently works as an ENT Registrar at Homerton University Hospital in London. He is a named author on 18 peer-reviewed publications with a combined citation count exceeding 4,600 and an h-index of 12. His research interests include tracheostomy safety, airway management, and multidisciplinary approaches to improving patient outcomes.