Staff caring for an 80 years old woman failed to hear a warning alarm alerting them to the fact that she had become disconnected from a breathing ventilator, an Inquest into her death heard.
On account of this being the second such incident in the critical care units of UHG, Coroner for West Galway, Dr Ciaran MacLoughlin, recommended that the HSE would issue a statement to assure members of the public that a review had taken place following this incident, and that ICU/HDU were safer places to be as a result.
Neither the nursing staff, nor the doctors doing their rounds at the time, heard the beeping noise to indicate that the life of Ann Downes, of 12 Bayview Heights, Ballybane, was in danger.
“This is the second occasion that this has happened (March 2012),” the Coroner pointed out to witnesses and family members.
“I was given to understand that corrective measure were put in place to ensure that this would never happen again. It is in the general public’s interest what happened, and why measures don’t seem to be in place.
“When it comes to the equipment, it doesn’t matter how ill the patient is, all must be treated the same. I know Mrs Downes was a very ill person, and that death was expected, but it is not reasonable to say that when the respirator malfunctioned no one knew.”
William Downes assumed his mother was asleep when he visited her on the afternoon of November 18 last year. He said that for about 30 minutes, no one came near her, until a male staff member called out her name. When he got no response from her, he became concerned, and Mr Downes was ushered out.
His mother, who had been admitted nearly a month earlier with hip and knee pain, was pronounced dead at 2.35pm.
An infection in her prosthetic knee had caused multi-organ failure, and she was unexpected to make a full recovery, but her medical team had hoped that she would be able to go home.
When her ability to breathe independently improved, she was moved from ICU (Intensive Care Unit) to HDU (High Dependency Unit), where the ratio of staff-patients is 1 to 2. There she was receiving a small level of ventilation support.
Consultant anesthetist, Mr Patrick Nelligan, saw her several times on the morning of November 18, and again at 1.30pm. He said that a team of doctors were doing their medical rounds at 2.15pm, but avoided Mrs Downes as she was being dealt with by the infectious diseases team, and the curtains were pulled around her bed space.
Nobody heard the alarm going off, until the nurse in charge, Sean O’Shaughnessy, was returning to the nurses station and noticed the beep – a recording of the same alarm was played for the Coroner, after which he noted: “It doesn’t seem to inspire any degree of urgency … you would be oblivious to it.”
When asked by the Coroner if Mr Downes – who was not present at the hearing – had heard the alarm, the nurse said: “he brought no attention to us at that time… there was nothing significant that said to me ‘stop what you’re doing, someone is in critical difficulty.’”
Assistant Director of Nursing, Catherine Lee, said the HDU unit was a very busy and often noisy ward, with telephones, equipment, and talking, combining to create “a cacophony of noise.”
When asked what measures had been implemented since Mrs Downes’ death, she said that the alarm settings were changed from default to being set according to the needs of the patient.
She said that the hospital’s response was to reduce unnecessary alarms, in order to make staff more aware of the important ones.
“We have reduced the alarms from 30,000 to 8,000 per week between ICU and HDU,” she said.
“There could often be nuisance alarms, such as if a patient coughs.”
However, Dr MacLoughlin was not satisfied. “You can make all the excuses – but why didn’t you see it or hear it,” the Coroner responded.
“This is in the public interest… I know you say that it’s a safe place to be, but was it safe on that day?
“It took 23 minutes before attention was drawn to this patient’s condition, by which time she was dead… The patient was in serious danger, and her condition should have been made known to staff immediately, irrespective of what was being done on the ward. There was a ward round going on at the time, there were numerous doctors around – there is something not right with that.”
Dr MacLoughlin returned a verdict in accordance with the medical evidence, that death was caused by respiratory failure due to bilateral bronchopneumonia.
“While I am aware that an internal review took place, this is the second occasion in which a ventilator was disconnected, and an internal review took place then also,” he said.
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