Patient died after hospital staff disconnected oxygen, court told
PUBLISHED: 15:32 15 January 2019 | UPDATED: 17:50 15 January 2019
A 70-year-old hospital patient died after staff transferred him between wards without his oxygen supply, an inquest heard.
A coroner ruled his death was an accident, after hearing the nurse preparing him for the transfer was distracted as she made arrangements for the move.
Retired maintenance engineer Peter Knight from Watlington, near King’s Lynn, had a terminal lung condition and needed oxygen 24 hours a day.
But senior coroner Jacqueline Lake heard that he was able to get around his home without hindrance and was independent.
Mr Knight’s wife Donna said in a statement an ambulance was called for her husband on Tuesday, June 5 after he became breathless.
He was admitted to the Queen Elizabeth Hospital, where he was diagnosed with a lung infection, the inquest in Lynn heard. Mr Knight appeared to be recovering and at around 7.30pm the following day was taken from the hospital’s medical assessment unit to Necton Ward.
But Mrs Knight, 54, said the nurse who oversaw the transfer did not check his oxygen levels before moving or on the way through the hospital.
Mr Knight was being pushed on a trolley by a porter.
His wife said as they came out of a lift, he began to pant and gasp. She said the nurse still did not check his oxygen levels.
When they arrived at Necton Ward, he had turned blue and was slumped down with his head on his chest.
Mr Knight had not been given oxygen on his journey through the hospital, the court was told. The oxygen pump he was connected to did not have batteries and would only work if it was plugged into the mains.
Mr Knight’s long term condition meant he would not be resuscitated, the court was told. He died at around mid-night.
Nurse Maija Muklicova said she had been distracted by other members of staff as she prepared Mr Knight for his transfer.
Under cross examination, she admitted she did not connect Mr Knight to an oxygen cylinder for the 10-minute journey.
Asked by Adam Korn, the family’s lawyer, what had caused the lack of oxygen, she said: “My fault. I didn’t follow correct procedure for the transfer of a patient on a high-level oxygen machine.”
A report into the incident by the hospital trust said patients should not be transferred with the machines because they did not have batteries. Staff should instead use cylinders.
The cause of death was given in court as acute exacerbation of pulmonary fibrosis, with a secondary cause of heart disease.
A consultant’s report said it was not possible to determine whether Mr Knight could have had days, weeks or months to live before succumbing to his pulmonary condition.
Emily Hodges, a clinical governance nurse at the hospital’s critical care unit, led an investigation into Mr Knight’s death.
She said the trust’s transfer policy was being reviewed, extra warnings were being attached to the oxygen machines and staff were being given additional training.
She said it was a concern that the nurse was distracted, adding: “The nurse involved has done a lot of reflection, she’s been spoken to by a lot of staff, she’s been through a lot.”
Summing up, the coroner said although Mr Knight could have died at any time, lack of oxygen did contribute to his death.
She said he had a long history of idiopathic pulmonary fibrosis and was oxygen dependant.
Mrs Lake said she did not find Mr Knight had been neglected by the hospital.
She said: “I am satisfied that the legal definition of accident is appropriate as a conclusion in this case so my conclusion is accident.”
She said she was satisfied the QEH had investigated events and recognised the seriousness of them.
She said she recognised the hospital was taking action and asked it write to update her on the outcome of a review of its transfer policy.
Outside court, Mr Knight’s family said in a statement: “We are pleased that the coroner has highlighted lack of oxygen was a significant cause of Peter’s untimely death.
“As a family, we are concerned to ensure no other family has to go through what we have. We now want to move on and remember all the good times we had with Peter.”
In a statement Emma Hardwick, chief nurse at the hospital, said: “I would like to extend my condolences to the family and again apologise for this tragic incident.
“We have reviewed our procedures and have put in place improved training for staff in the use of oxygen equipment. We also hold regular reviews of these processes.
“We will also be taking on board the comments made by the coroner today.”