Source · Prevention of Future Deaths
Doreen Mattinson
Ref: 2016-0156
Date: 18 Apr 2016
Coroner: Jacqueline Devonish
Area: London Inner North
Responses identified: 0 / 1
View PDF
Oxygen was incorrectly administered at a care home, with staff failing to recognise appropriate emergency oxygen levels and positioning. The clinical manager, a registered nurse, lacked training in oxygen administration.
Date
18 Apr 2016
56-day deadline
13 Jun 2016
Responses identified
0 of 1
Coroner's concerns
Oxygen was incorrectly administered at a care home, with staff failing to recognise appropriate emergency oxygen levels and positioning. The clinical manager, a registered nurse, lacked training in oxygen administration.
View full coroner's concerns
(1) The London Ambulance Service attended Mrs Mattinson on 12 November 2015 and made a Safeguarding Report relating to the use of the oxygen. It had been reported that Mrs Mattinson had been lying supine on the bed saturating at 84% and struggling to breath. The oxygen could not be heard to be running and it was noted that only 1 litre was running when this should have been a15 litre flow with the mask applied.
(2)There was no recognition by the Clinical Manager or those present on 12 November 2015 of the level of oxygen to be used in an emergency situation or as to the importance of sitting the patient in an upright position. (3)There was no evidence of training of the Clinical Manager, who was a registered nurse and the only member of staff on the residential unit on that day who would be expected to administer oxygen.
(2)There was no recognition by the Clinical Manager or those present on 12 November 2015 of the level of oxygen to be used in an emergency situation or as to the importance of sitting the patient in an upright position. (3)There was no evidence of training of the Clinical Manager, who was a registered nurse and the only member of staff on the residential unit on that day who would be expected to administer oxygen.
Report sections
Investigation and inquest
On 9 December 2015 I commenced an investigation into the death of Doreen Mattinson, aged 80 years. The investigation concluded at the end of the inquest on Thursday 14 April 2016. The conclusion of the inquest was that the medical cause of death was Bronchopneumonia and Pulmonary Embolus due to Carcinoma of the Left Lung. The conclusion as to the cause of death was that the death was from natural causes.
Circumstances of the death
Doreen Mattinson became a resident of Acorn Care Home on 2 February 2015 when she had been assessed as not having the capacity to reside in sheltered accommodation.
On 7 July 2015 Hackney Social Services issued a Deprivation of Liberty Order due to her inability to make decisions about her accommodation, care or treatment as a result of her diagnosis of dementia. Other comorbidities included Chronic Obstructive Pulmonary Disease (COPD), Cerebrovascular Accident (CVA) and recurrent falls.
Her health remained stable until 27 October 2015 when she developed a cough. The GP attended Doreen Mattinson at the request of Acorn Care Home on six occasions between 28 October and 11 November 2015 due to concerns about the cough, and a possible CVA. She was initially treated with a nebuliser, given her COPD. When the cough had not improved by 11 November she was treated with antibiotics for a suspected chest infection.
On 12 November 2015 Doreen Mattinson deteriorated rapidly and with laboured breathing. The Clinical Manager, who is a registered nurse, attended Mrs Mattinson together with two Senior Health Care Assistants. The Clinical Manager administered oxygen at a 1 litre flow utilising a lifeline cylinder and mask.
On 7 July 2015 Hackney Social Services issued a Deprivation of Liberty Order due to her inability to make decisions about her accommodation, care or treatment as a result of her diagnosis of dementia. Other comorbidities included Chronic Obstructive Pulmonary Disease (COPD), Cerebrovascular Accident (CVA) and recurrent falls.
Her health remained stable until 27 October 2015 when she developed a cough. The GP attended Doreen Mattinson at the request of Acorn Care Home on six occasions between 28 October and 11 November 2015 due to concerns about the cough, and a possible CVA. She was initially treated with a nebuliser, given her COPD. When the cough had not improved by 11 November she was treated with antibiotics for a suspected chest infection.
On 12 November 2015 Doreen Mattinson deteriorated rapidly and with laboured breathing. The Clinical Manager, who is a registered nurse, attended Mrs Mattinson together with two Senior Health Care Assistants. The Clinical Manager administered oxygen at a 1 litre flow utilising a lifeline cylinder and mask.
Copies sent to
Hackney Social Services and the CQC
Similar PFD reports
Related inquiry recommendations
COVID-19 Inquiry
Triennial Parliamentary Resilience Reports
COVID-19 Inquiry
Fit-Testing Preparedness
Manchester Arena Inquiry
Use recording equipment during exercises
Manchester Arena Inquiry
Training on use of recording equipment
Manchester Arena Inquiry
Ten Second Triage training for frontline staff
Jermaine Baker Inquiry
Police medic training on catastrophic haemorrhage
Anthony Grainger Inquiry
Maximum Continuous Duty Period for AFOs
Baha Mousa Inquiry
Communicating Sight Deprivation Reasons
Ladbroke Grove Inquiry
Endorse adoption of defensive driving teaching and practice by TOCs
Ladbroke Grove Inquiry
Provide signallers with emergency stop options and regular situational briefings on use
Report details
- Reference
- 2016-0156
- Date of report
- 18 April 2016
- Coroner
- Jacqueline Devonish
- Coroner area
- London Inner North
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: 13 Jun 2016.
Sent to
- Acorn Lodge Care Home