Source · Prevention of Future Deaths
Simon Harper
Ref: 2016-0410
Date: 9 Nov 2016
Coroner: Sarah Slater
Area: South Yorkshire (West)
Responses identified: 0 / 1
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Insufficient and undocumented training for nurses on portable oxygen cylinder use, following task reassignment, resulted in a critical error during patient transfer.
Date
9 Nov 2016
56-day deadline
26 Jan 2017
Responses identified
0 of 1
Coroner's concerns
Insufficient and undocumented training for nurses on portable oxygen cylinder use, following task reassignment, resulted in a critical error during patient transfer.
View full coroner's concerns
_ The inquest heard that in November 2010 the act of connecting a patient to an oxygen cylinder for transfer was reassigned from porter staff to nursing staff: Upon the reassignment of the task, one session of training was provided by a external company to a small number of nursing staff who were on duty at the time. There is no record regarding the contents of the induction/training or who was present at the time. In addition, the Trust confirmed that since that date there has been no formal training and they have relied on 'peer to peer' training: In addition, no register of individuals trained or content Of training is documented . There is no record of who has and has not received relevant training and no audit is in place to assess the appropriateness of this 'on the job' his training The inquest heard that the nurse responsible for connecting the patient to the oxygen cylinder did not turn the valve to allow oxygen flow. It is probably that this lead to the cardiorespiratory arrest although it was accepted no-one could be certain of this The Secretary of State for Health is asked to consider whether it is appropriate for training to be provided and documented regarding the use of portable oxygen cylinders for patients_ The implementation of Transfer of Patients Policy should also be considered as those available did not cover this issue
Report sections
Investigation and inquest
On 15th March 2016 commenced an investigation into the death of Mr Simon Timothy Harper _ The investigation concluded at the end of the inquest on 28th October 2016. The conclusion of the inquest was the Mr Simon Timothy Harper died from; Multiple Organ Failure 1b) Pneumonia Alcohol related liver disease A narrative conclusion was recorded as follows: Mr Harper was admitted to the Northern General Hospital on the 6th March 2016 with jaundice and abdominal distention. His condition deteriorated and he was transferred to the intensive care unit on the 7th March 2016. However, during the transfer Mr Harper's oxygen cylinder was not turned on and it is likely this lead to him suffering a cardiac arrest whilst on route. Mr Harper was successfully resuscitated but he continued to deteriorate and died on the gth March 2016. It is not possible to state what effect; if any; this cardiac arrest has had on Mr Harper's death. 1a) 1c)
Circumstances of the death
Mr Harper was admitted to the Northern General Hospital on 6th March 2016 with jaundice and abdominal distention: On the 7th March 2016, Mr Harper suffered liver failure, kidney failure and respiratory failure Mr Harper was receiving oxygen via non-rebreathe mask from the main hospital wall supply to support his lung function. Later that evening the patient underwent a Critical Care Review who agreed a transfer to the General Intensive Care Unit, In order to transfer Mr Harper portable oxygen supply was required and this was supplied by portering department: It is the responsibility of nursing staff to connect the cylinder to Mr Harper_ On route to the General Intensive Care Unit the patient; Mr Harper suffered a sudden deterioration and it was noticed that the portable oxygen cylinder had not been turned on. Mr Harper suffered cardiorespiratory arrest to which resuscitation attempts were successful. He was admitted to the General Intensive Care Unit shortly after midnight at which point he was deeply comatose and anuric_ On gth March 2016 treatment was withdrawn death occurred at 1800_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action;
Inquest conclusion
Mr Harper was admitted to the Northern General Hospital on the 6th March 2016 with jaundice and abdominal distention. His condition deteriorated and he was transferred to the intensive care unit on the 7th March 2016. However, during the transfer Mr Harper's oxygen cylinder was not turned on and it is likely this lead to him suffering a cardiac arrest whilst on route. Mr Harper was successfully resuscitated but he continued to deteriorate and died on the gth March 2016. It is not possible to state what effect; if any; this cardiac arrest has had on Mr Harper's death. 1a) 1c)
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Report details
- Reference
- 2016-0410
- Date of report
- 9 November 2016
- Coroner
- Sarah Slater
- Coroner area
- South Yorkshire (West)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 26 Jan 2017.
Sent to
- Department for Health