PIF member the Royal College of Anaesthetists (RCoA) has developed a campaign and training materials following the avoidable death of Glenda Logsdail.

The resources were developed in collaboration with the Difficult Airway Society and the Association of Anaesthetists.


A coroner’s report to prevent future deaths found Glenda Logsdail died at Milton Keynes University Hospital in 2020 because of a misplaced breathing tube.

Her death was preventable and the report outlined specific actions to be taken nationally.

RCoA’s joint campaign included 5-Minute Flashcards – designed to take no more than 5 minutes of theatre staff time. 

There is a flashcard per topic, with a few short, simple questions.

They are aimed at stimulating discussion, raising awareness of specific patient safety systems and encouraging all theatre staff to contribute.


The flashcards were rolled out at in 24 surgical theatres at the Gloucestershire Hospitals NHS Foundation Trust. 

The response from staff has been enthusiastic, including:

  • “More please!”
  • “A weekly flash card sim would be beneficial”
  • “Breaks down barriers, allowing all staff to speak up”.

The Gloucestershire team highlighted the importance of involving users when producing health information.

The support of local area leads underpinned the roll-out.

Subsequently, more staff have been involved, with requests for different topics and areas.

Cards are now being written by a range of staff covering different training needs across the trust.

Read the Gloucestershire case study on the RCoA website here.

Visit the Gloucestershire 5-Minute Flashcard hub here.