The inquest touching the death of Mrs Pamela Inglis was heard before HM Coroner Mrs Louise Slater on the 09/01/2023.
Pamela Inglis was admitted to Doncaster Royal Infirmary on the 05/04/2022 with shortness of breath. She was diagnosed with COPD and admitted to the critical care unit for Non-Invasive Ventilation.
Pamela made good progress and was stepped down to a ward on the 13/04/2022. Pamela however continued to require continuous oxygen to maintain her oxygen saturation levels.
On the 21/04/2022 Pamela was found in her side room with her oxygen mask disconnected. She was unresponsive with no respiratory effort, no pulse and was cold to touch. A Nurse gave evidence that Pamela was observed 30 mins earlier and was fine.
This death has some striking similarities to the death of a patient at Harrogate District hospital and a further patient at a hospital in Wrexham:
Much to the family’s dismay, it transpires that there is no guidance or protocols in place to manage patients with respiratory illnesses requiring breathing support on a general ward, like there would be in critical care or on a respiratory support unit.
The oxygen supply did not have an alarm and observations were set by nurses with reference to a patient’s news score. Hospital staff gave evidence that checks every hour were more than enough even though the patient had been agitated through the night, pulling at her mask, was hard of hearing and semi-compliant with her call bell.
The Coroner recorded the following narrative conclusion:
Mrs Inglis was admitted to Doncaster Royal Infirmary on the 05/04/2022 with increased shortness of breath. She was treated for pneumonia and COPD with antibiotics, steroids, fluids and oxygen therapy. Her condition was improving when she was found collapsed in her room.
The oxygen tubing which should have been providing oxygen was disconnected and caused her death. The medical cause of death was a chest infection and hypoxia due to abrupt removal of oxygen supply.
The family was represented by our Head of Personal Injury and Inquest Law, Gareth Naylor.