Department of Anaesthesia, Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK.
In the South-West Thames region of the United Kingdom, during a 5-year period from 1999 to 2003, there were 20 failed tracheal intubations occurring in 4768 obstetric general anaesthetics (incidence 1 : 238). In half of the 16 cases for which the patient's notes could be examined there was a failure to follow an accepted protocol for failed tracheal intubation.