Barnsley Hospital NHS Foundation Trust

3. Mrs A complains about the care and treatment provided by Barnsley Hospital NHS Foundation Trust (the Trust) to her husband, Mr A. She says the Trust disconnected her husband’s oxygen which caused a sudden deterioration in his condition. Mr A did not recover and sadly died.

4. Mrs A says her husband’s death may have been prevented if the Trust had not disconnected his oxygen. She says the death of her husband and the circumstances under which he died caused her a great deal of distress which she still struggles with today.

5. Mrs A would like the Trust to acknowledge the failings and apologise. She would also like the Trust to put in place service improvements and make a financial payment.

6. Mr A had a medical history of prostate cancer, chronic obstructive pulmonary disease (COPD) and bronchiectasis (a chronic lung disease which causes damage to airways, persistent cough and increased mucus). He lived with severe frailty, needed support with his daily activities and long-term oxygen therapy (continuous supplementary oxygen treatment at home) to maintain his oxygen saturation levels (the concentration of oxygen in the bloodstream).

7. He was admitted to the Trust due to an exacerbation of his COPD, increasing breathlessness and constipation. During his admission Mr A spent most of his time in bed and required full assistance from Trust staff. Due to the risks posed by his poor mobility and frail condition the Trust put in place a 2 hourly repositioning regime.

8. To treat his exacerbation of COPD the Trust provided oxygen therapy through a venturi mask (a mask that covers the mouth and nose to deliver constant oxygen regardless of the patient’s respiratory rate) at a 40% flow rate to achieve and maintain a target oxygen saturation level of 88-92%. The Trust provided additional treatment throughout his admission with oramorph (liquid morphine) to help ease his breathlessness, intravenous antibiotics for suspected chest infection and laxatives for his constipation.

9. As a result of the treatment Mr A’s condition improved. His blood gasses (the level of oxygen and carbon dioxide in the blood and ph level) improved, his C-Reactive protein (CRP, a protein produced by the liver in response to inflammation which increases in a patient suffering with an infection) decreased from 130 on admission to 50 a week later and his white blood cell count (which increases in patients suffering with an infection) improved.

10. Mr A’s oxygen saturation levels remained within the target range of 88-92% whilst the Trust provided oxygen through the venturi mask. In an attempt to wean Mr A onto a lower level of oxygen therapy the Trust changed his oxygen to 4 litres per minute through a nasal cannula (a medical device used to deliver supplemental oxygen directly into the nostrils).

Mr A’s oxygen saturation level dropped after this change and the Trust increased the level of oxygen provided through the nasal cannula to 5 litres per minute which brough him back to within his target level.

11. The Trust changed his oxygen again to 4 litres per minute through a non-rebreather mask (a mask that covers the mouth and nose designed to provide supplementary oxygen to a patient who can breathe on their own but require a significant amount of oxygen due to their medical condition). Mr A’s oxygen saturation level dropped to 80% and the Trust increased his oxygen to 15 litres per minute which brought him back to within his target level. As the attempts to wean Mr A to a lower level of oxygen therapy had been unsuccessful the Trust changed his oxygen therapy back to a venturi mask at a 40% flow rate.

12. Throughout the early hours, and during the morning of the day of the incident, Mr A’s oxygen saturation level remained within the target range.

13. At around 11.20am on the day of the incident two Trust staff members attended to Mr A to provide personal care, reposition him in his bed and change his bed sheets. After they left, Mrs A went in to see her husband and found him to be distressed, disorientated and struggling to breathe. Mrs A called for the nurse who attended and found that although Mr A still had his oxygen mask in place, it had become disconnected from the supply outlet on the wall. The nurse reconnected the oxygen supply and activated the emergency call system for further assistance. Mr A did not recover and sadly died at 11.40am.

14. The Trust investigated this incident but was unable to establish precisely when during the personal care intervention Mr A’s oxygen became disconnected from the wall. The Trust was also unable to establish how long the oxygen had been disconnected before it was identified and reconnected by the nurse. The Trust acknowledged the care during this incident was poor but concluded that the disconnection of his oxygen had no impact on Mr A’s outcome.

15. We acknowledge the precise length of time the oxygen was disconnected cannot now be confirmed. It is clear it became disconnected during the personal care intervention and was only identified and reconnected by the nurse who attended after Mrs A raised her concerns. This sequence of events indicates on balance of probabilities that the oxygen was disconnected for a few minutes rather than a few seconds.

19. The BMJ study says:

‘A high risk of poor clinical outcomes associated with a history of severe or multiple exacerbations has been described, even in the absence of severe lung function impairment. Indeed, a severe acute exacerbation of COPD requiring hospitalisation has been shown to result in a case fatality rate of 15.6%.’

20. The BTS guidance says:

‘Oxygen should be prescribed to achieve a target saturation of 94–98% for most acutely ill patients or 88–92% or patient-specific target range for those at risk of hypercapnic respiratory failure.

Oxygen delivery devices and flow rates should be adjusted to keep the oxygen saturation in the target range. Prompt clinical assessment is required if oxygen therapy needs to be initiated or increased due to a falling saturation level.

Staff should check the oxygen supply and connections on a regular basis because there have been serious incidents due to disconnection or misconnection of oxygen supplies.

The administering healthcare professional should note the oxygen saturation before starting oxygen therapy wherever possible but never discontinue or delay oxygen therapy for seriously ill patients.’

21. The NICE guidance supports this and says:

‘An exacerbation is a sustained worsening of the patient's symptoms from their usual stable state which is beyond normal day-to-day variations and is acute in onset. When providing oxygen therapy during exacerbations of COPD prescribe oxygen to keep the oxygen saturation of arterial blood within the individualised target range if necessary.’

22.The ERS study says an interruption of oxygen treatment of 5 minutes can affect brain function in COPD patients and an interruption of 10 minutes can be fatal.

23. As set out in the BMJ study it is accepted that some patients may not recover following admission to hospital for exacerbation of COPD. There are no lung function scores, clinical frailty scores, echocardiogram reports or any further information about Mr A’s prostate cancer in the records provided to us by the Trust. However the records do provide evidence to indicate his condition improved a great deal during his admission up until the sudden deterioration on the day of the incident.

24. The BTS and NICE guidance say it is important to maintain the patient’s oxygen saturation within the target range and not discontinue it. Mr A was on long-term oxygen for his COPD prior to his admission and our adviser said as this was an essential part of his care it would not usually be interrupted or disconnected.

25. The information provided to us by the Trust gives a conflicting account of the timings of the incident. The statement to the coroner from the Matron says the personal care intervention was completed at 11.20am. The records say 11.20am was when Mrs A approached the nurse after finding her husband struggling to breathe. The statement to the coroner from the nurse says 11.20am was the time they attended to reposition Mr A and change his bed sheets.

26. In her account of the incident Mrs A said she arrived at ward at 11am and the nurses were changing the bed sheets. She says she went to find a doctor to speak to and when she returned she stayed outside the room as the nurses were still changing the bed sheets. She says she went in after the nurses left and immediately noticed her husband was in distress and struggling to breathe and asked for help.

27. There are discrepancies in the evidence provided to us about the specific timings during this incident. However the evidence does provide a clear sequence of events as follows:

• The nurses attend to complete the personal care intervention. Mr A’s bed sheets are changed and he is repositioned in his bed. His oxygen mask is checked to ensure it is in position, but it is not checked to ensure it is still connected to the oxygen supply at the wall.

• Mrs A returns to her husband’s room after the nurses have left and finds him struggling to breathe.

• Mrs A seeks help, the nurse comes to room and finds Mr A in respiratory distress, the disconnection of the oxygen tube from the wall is identified and emergency help requested.

• Mr A does not recover and dies a few minutes later.

28. It is likely, on the balance of probabilities that Mr A’s oxygen became disconnected from the supply at the wall during the personal care intervention either whilst the nurses were manoeuvring him in order to change the bed sheets or repositioning him in his bed. We cannot say at what point, but it is likely to have happened during the personal care intervention and not after it had been completed.

29. As set out in the ERS study a short period of interruption of oxygen in a patient with exacerbation of COPD who is on long term oxygen therapy can have a significant impact. In this case the precise length of time his oxygen was disconnected cannot be confirmed but the sequence of events, and the accounts of the activities being performed during the personal care intervention, indicates on balance of probabilities Mr A was likely to have been without his oxygen for several minutes.

30. We carefully considered Mrs A’s view that the disconnection of his oxygen led to the deterioration in her husband’s condition. We acknowledge Mrs A’s account of how distressing this incident was. We also considered the information provided to us by the Trust and the advice we received.

31. We acknowledge that Mr A had significant health concerns and that his COPD and associated lung conditions were chronic and incurable. However the evidence in the records provided to us by the Trust does not support its view that the disconnection of his oxygen had no impact on Mr A’s condition at that time or his outcome.

32. The records indicate the plans for Mr A’s future care were moving towards palliative care. However palliative care can be provided for extended periods and it is not only provided for patients’ for whom death is thought to be imminent. Although the Trust’s plans for future palliative care were reasonable given the incurable and progressive nature of his condition there is no indication in the records that the Trust felt Mr A’s death was imminent. The records confirm up until the day of the incident the Trust provided full active treatment for all of Mr A’s conditions and there is no evidence to indicate any treatment had been withdrawn.

33. The records indicate all the relevant test results and observations showed a steady improvement in his condition back towards his base level up until the date of the incident. There is no evidence in the records to indicate his sudden deterioration at this time can be attributed to any other aspect of his condition.

34. We cannot say the disconnection of his oxygen had no impact on Mr A. The evidence indicates after being relatively stable and having shown significant improvement during his admission, he suffered a sudden, significant deterioration after his oxygen was disconnected. We found, on balance of probabilities, the disconnection of his oxygen lead to the deterioration he suffered at that time which ultimately caused his death. We found Mr A may not have died at this time if his oxygen had not become disconnected.

1. We have decided to uphold Mrs A’s complaint. We acknowledge how upsetting this incident and the death of her husband was and that it continues to cause her considerable distress.

2. We found the accidental disconnection of Mr A’s oxygen led to a sudden deterioration in his condition. We found, on balance of probabilities, Mr A may not have died at that time if the Trust had ensured his oxygen supply remained connected.