Source · Prevention of Future Deaths
Kay Sheard
Date: 21 Dec 2015
Coroner: John Gittins
Area: North Wales (East and Central)
Responses identified: 0 / 1
View PDF
Pulse oximeter alarm settings are fixed at a routine level rather than being adjusted to individual patient baselines, risking unnoticed significant oxygen desaturation.
Date
21 Dec 2015
56-day deadline
15 Feb 2016
Responses identified
0 of 1
Coroner's concerns
Pulse oximeter alarm settings are fixed at a routine level rather than being adjusted to individual patient baselines, risking unnoticed significant oxygen desaturation.
View full coroner's concerns
During the procedure the Deceased's oxygen saturations were being monitored by a pulse oximeter for which was advised that the alarm settings are routinely set at 85% However all evidence indicated that it was not the actual level of reading which would be significant for a patient but rather the amount by which saturations had dropped from the patients normal base level. Notwithstanding this, the evidence indicated that this would not be taken into account when fixing an alarm setting level and am therefore concerned that there exists a potential risk to patients which could be reduced or eliminated by ensuring that the alarm level correctly reflects the individual patient's condition. Kay
Report sections
Investigation and inquest
On the 8th of January 2015 commenced an investigation into the death of Michelle Sheard (DOB 6.1.73,DOD 6.1.15). The investigation concluded at the end of the inquest on the 16th of December 2015. The cause of death was 1(a) Unascertained and recorded an Open Conclusion
Circumstances of the death
The Circumstances of the death are that on the 6th of January 2015 the Deceased underwent an outpatient procedure under sedation at Glan Clwyd HGospital for the removal of gall stones form the bile duct: Upon completion of the procedure she went into cardiorespiratory failure for reasons which could not be established at a Post Mortem nor from evidence at the inquest,
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisations have the power to take such action.
Similar PFD reports
Related inquiry recommendations
Infected Blood Inquiry
HIV Eligibility Start Date
Infected Blood Inquiry
Interferon Treatment Impacts
Infected Blood Inquiry
Special Category Mechanism
Infected Blood Inquiry
Effective Treatment - Earnings Floor
Infected Blood Inquiry
Deeming of Severity Bands
Infected Blood Inquiry
Evidence of Diagnosis Date
Infected Blood Inquiry
Financial Loss and Care
Infected Blood Inquiry
Exceptional Loss Evidence
Infected Blood Inquiry
Unethical Research Award
Infected Blood Inquiry
Wider Definition of Unethical Research
Report details
- Date of report
- 21 December 2015
- Coroner
- John Gittins
- Coroner area
- North Wales (East and Central)
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: 15 Feb 2016.
Sent to
- BCUHB, Ysbyty Gwynedd