Objectives: We aimed to characterise the use of tracheostomy procedures for all COVID-19 critical care patients in England and to understand how patient factors and timing of tracheostomy affected outcomes. Design: A retrospective observational study using exploratory analysis of hospital administrative data. Setting: All 500 National Health Service hospitals in England. Participants: All hospitalised COVID-19 patients aged ≥ 18 years in England between March 1st and October 31st, 2020 were included. Main outcomes and measures: This was a retrospective exploratory analysis using the Hospital Episode Statistics administrative dataset. Multilevel modelling was used to explore the relationship between demographic factors, comorbidity and use of tracheostomy and the association between tracheostomy use, tracheostomy timing and the outcomes. Results: In total, 2,200 hospitalised COVID-19 patients had a tracheostomy. Tracheostomy utilisation varied substantially across the study period, peaking in April-June 2020. In multivariable modelling, for those admitted to critical care, tracheostomy was most common in those aged 40-79 years, in males and in people of Black and Asian ethnic groups and those with a history of cerebrovascular disease. In critical care patients, tracheostomy was associated with lower odds of mortality (OR: 0.514 (95% CI 0.443 to 0.596), but greater length of stay (OR: 41.143 (95% CI 30.979 to 54.642). In patients that survived, earlier timing of tracheostomy (≤ 14 days post admission to critical care) was significantly associated with shorter length of stay. Conclusions: Tracheostomy is safe and advantageous for critical care COVID-19 patients. Early tracheostomy may be associated with better outcomes, such as shorter length of stay, compared to late tracheostomy.

Introduction: Litigation against the National Health Service (NHS) in England is rising, costing £2.4 billion in 2018/19. The aim of this study was to determine the incidence and characteristics of otolaryngology clinical negligence claims in England. Methods: A retrospective review was undertaken of all clinical negligence claims in England held by NHS Resolution relating to otolaryngology between April 2013 and April 2018. Analysis was performed using information for cause, patient injury and claim cost. Where claim information was adequately detailed, the authors categorised claims by subspecialty, diagnosis and operation. Results: A total of 727 claims were identified with an estimated potential cost of £108 million. From these, 463 were closed claims. Including open claim reserves, the mean cost of a claim was £148,923. Head and neck surgery was the subspecialty with the highest number of claims (n=313, 43%) and highest cost (£51.5 million) followed by otology (n=171, £24.5 million) and rhinology (n=171, £13.6 million). Over half of claims were associated with an operation (n=429, 59%) where mastoid surgery (n=46) and endoscopic sinus surgery (n=46) were equally associated with the greatest number of claims. The most frequent reasons for litigation included failure or delay to diagnose (n=178, 25%) failure or delay to treat (n=136, 19%), intra-operative complications (n=130, 18%) and failure of the consent process (n=107, 15%). Discussion: Clinical negligence claims in otolaryngology are related to several different components of patient management and is not limited to post-operative complications. This study highlights the importance of robust pathways in outpatient diagnostics and the consenting process, especially in the high-risk speciality of head and neck surgery, in order to deliver better patient care and reduce the impact of litigation.