Patient died after not receiving oxygen during Queen Elizabeth Hospital transfer, inquest hears
Lynn's Queen Elizabeth Hospital has said it has implemented changes following the death of a patient due to a lack of oxygen in June.
An inquest at King's Lynn Magistrates Court heard yesterday that Peter Knight, of Watlington, died at the age of 70 after losing oxygen during a transfer from the medical assessment unit to the Necton ward on Tuesday, June 6, at the hospital.
As a result of the death, critical care governance nurse Emily Hodges said changes have been made such as transfer training days every three months and ensuring that transfer flowcharts are available in every ward.
After expressing her concern at the lack of notes during the three hours leading to Mr Knight's death, all staff have had training on how to score the notes.
Nurse educator experts in the relevant areas will also provide bedside training.
"An investigation was launched looking at all the factors and pinpointing the cause of death," said Mrs Hodges.
Mr Knight died just before midnight after his oxygen supply was disconnected during the transfer.
The court heard how a porter had accidentally disconnected the supply while a nurse was attending to something else on the ward.
As a result, Mrs Hodges said extra warning signs were attached to oxygen machines throughout the hospital stating they should not be unplugged.
Patients also should not be transferred with the machines because they do not have batteries. Cylinders should be used instead.
Mr Knight's wife Donna, 54, provided a statement to the court, saying Peter had an asbestosis condition which had previously been managed at home. He was given oxygen 24 hours a day.
Mrs Knight recalled Peter calling out "Don, Don why am I not getting any oxygen?" during the transfer to the Necton ward.
She said: "He was mumbling and very cold. He was very confused and said 'did I have a fall?'
"I asked the doctor if he was going to die and he said he did not know. This conversation took place one hour after Peter had been joking and laughing downstairs.
"I called my children at 11.43pm to say Peter had died and they were devastated as only an hour or two before they were told he was in good health and returning home."
Mrs Knight was told in a meeting afterwards that the wrong machine was used during the transfer and he was not receiving any oxygen.
Nurse Mia Muklicova, who has been qualified for one-and-a-half-years as a nurse, said Mr Knight had an early morning score of three which indicated respirational distress.
After being told he would be moved to the Necton ward for respirational care, nurse Muklicova said an error occurred in which she was not able to check everything was connected properly.
She said she had been distracted by the doctor and had to attend to something else, while the trained porter said he was happy to assist Mr Knight instead.
By the time Mr Knight had made the 10 minute journey via a lift to the Necton ward, nurse Muklicova said "he began to look very pale at this point" and noticed "his fingers were blue".
After being questioned by Adam Korn, the family's lawyer, Mrs Muklicova said: "The lack of oxygen was my fault. I did not follow the correct procedure.
"I was shocked the machine did not have a battery and was it was never connected to an oxygen cylinder.
"I tried my best but because of the distraction on the ward, it was very hard."
She added she is now working on the West Newton ward with dementia patients and not with asbestosis.
The court heard how Mr Knight's post-mortem examination found he died of acute exacerbation of idiopathic pulmonary fibrosis and ischaemic heart disease.
Consultant Dr Mathialagan's report said Mr Knight had last been reviewed in 2017 and his condition had deteriorated from when he was first diagnosed with lung disease in 2012. This was reclassified as asbestosis in 2016.
He said Mr Knight had been receiving antibiotics in addition to medicine for lung disease.
"If he had received oxygen during the transfer I suspect he would not have died as he did but whether he would have survived for days, weeks or months is not for me to say," he added.
Summing up, senior coroner Jacqueline Lake, said although the lack of oxygen may have aggravated Mr Knight's hypoxia, "arguably, given the aggressive nature of the condition, it would not have impacted on the overall outcome."
Mrs Lake said she was satisfied that the legal definition of accident was an appropriate conclusion.
This came after the family's lawyer had made the case for neglect being a contributing factor for the death, which she dismissed.
But Mrs Lake said: "It was an unintended consequence of an unintended error."
She continued: "Having considered the evidence I do find at the time of transfer Mr Knight’s oxygen levels were stable, and immediately before the transfer.
“Mr Knight was oxygen-dependent, and by the time of his arrival on Necton ward, although I’m satisfied that he may have died at any time, not being connected to oxygen did cause or may have contributed to his death.
“Mr Knight had a long-standing history of idiopathic pulmonary fibrosis and was oxygen-dependent.
“He was admitted to hospital on 5 June 2018, and diagnosed with a chest infection on the 6 June 2018. Mr Knight was transferred from the medical assessment unit to Necton ward during which time he was not connected to the oxygen cylinder.
“On arrival at the ward he was seen to be hypoxic. He was given oxygen and died later that evening.
“On that basis, it is not a natural cause of death.”
Mrs Lake reiterated Mr Knight had been diagnosed with lung disease in 2014, which had been reclassified as asbestosis in 2016.
"Mr Knight's condition was managed at home and in previous 10 months he was on oxygen 24 hours a day, but he was still able to maintain his day to day life, and was otherwise independent, with assistance from Mrs Knight and her daughter."
Following the verdict, a statement on behalf of the family, said: "We are very pleased that the coroner highlighted that the lack of oxygen was a significant cause of Peter’s untimely death and pleased that the coroner has asked the trust to report back in March 2019 to confirm progress has been made.
"As a family we are concerned to ensure that no other family has to go through what we have.
“We now hope to move on and remember all the good times we had with Peter.”
A statement from the Queen Elizabeth Hospital issued after the inquest by chief nurse Emma Hardwick said: "I would like to extend my condolences to the family and again apologise for this tragic incident.
"When a patient dies unexpectedly in our care an investigation is undertaken and improvements implemented.
"We have reviewed our procedures and have put in place improved training for staff in the use of the oxygen equipment. We now also hold regular reviews of these processes.
"We will also be taking on board the comments made by the coroner today.”
