Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0525, written 3 Dec 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Dec 2014 |
|---|---|
| Reference | 2014-0525 |
| Deceased | Sandra Danks |
| Coroner | Clare Bailey |
| Coroner area | Teesside |
| Category | Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Philips Respironics 2. British Oxygen 1 CORONER I am Clare Bailey, acting senior coroner, for the coroner area of Teesside. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 3 December 2014, I commenced an investigation into the death of Sandra Danks age 71. The investigation concluded at the end of the inquest on 3 December 2014. The conclusion of the inquest was that Mrs Danks died of an accident. The medical cause of her death has been recorded as Anoxia due to Oxygen Pump Failure. Her death was also contributed to by Ischaemic and Hypertensive Heart Disease and Fatty Liver. 4 CIRCUMSTANCES OF THE DEATH Mrs Danks required 24 hour oxygen at home due to her medical conditions. The oxygen was fed through tubing directly from an ‘Everflo API’ by Respironics. The machine was situated on the upstairs landing of the property. Various tubes were connected to a junction switch which could be used to whatever setting was required, allowing Mrs Danks to have access to oxygen supply. At about 8.30am Mrs Danks’ son telephoned who was away from home, to say the electricity supply had gone off. rushed home to assist his wife. She had been unable to utilise the spare oxygen bottle nearby once the electricity shortage had switched off her main oxygen apparatus. She passed away as a result. At the Inquest informed me that there had been a similar incident in September 2014. Fortunately, he was able to return home in time to access the spare oxygen bottle and provide his wife with oxygen. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) An interruption in the electricity supply to the main oxygen apparatus stopped the oxygen provision and there was no back up on the main oxygen apparatus to continue to provide oxygen, thus leaving Mrs Danks in a very vulnerable position. 1 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 28 January 2015. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 DATE SIGNED BY CORONER 2
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
BOC Healthcare Patient Service Centre Priestley Road Worsley, Manchester M28 2UT Telephone: 0800 136 603 Facsimile: 0800 169 9989 C Bailey The Coroners Service Middlesbrough Town Hall Albert Road Middlesbrough TS12Q) 19" January 2015 Dear Ms Bailey, Re: Sandra Danks We are in receipt of your letter dated 3 December 2014. BOC takes patient safety very seriously and has in place robust policies and procedures to ensure the safety of patients using BOC’s Oxygen Concentrators. BOC has conducted a full review of both its general policies and procedures in respect of the supply of oxygen concentrators and also a full review of BOC’s actions in respect of this specific patient since the initial supply of oxygen in July 2013, BOC delivers oxygen to home patients as part of its North East NHS contract. BOC has held the contract since 2011 following a public procurement tender process. BOC follows to the letter the requirements of such contract in terms of the specification given by North East NHS for the equipment and services provided and which are determined by the primary caregivers. As part of an oxygen concentrator installation - for long term oxygen therapy - the contract stipulates that BOC will deliver and train the patient on the use of a back-up oxygen cylinder in case of equipment malfunction or power failure. The back-up oxygen cylinder lasts 8 hours at the patient's prescribed flow rate and BOC will attend to the equipment reported fault within that period of time. Following receipt of an order from this patient’s respiratory clinician on 26 July 2013, BOC’s Patient Service Representative installed an oxygen concentrator at this patient’s home on 27 July 2014. In line with BOC’s contract with North East NHS and BOC’s policies and procedures, BOC also supplied a back-up oxygen cylinder and delivered training to this patient on all aspects of the oxygen equipment delivered. Please find attached BOC’s oxygen concentrator equipment guide and BOC’s home oxygen cylinders equipment guide. The training provided to this patient, and all other patients supplied with an oxygen concentrator, covers the content of these equipment guides and copies of the equipment guides were supplied to this patient for further reference. During the installation of an oxygen concentrator, it is emphasised that the back-up oxygen cylinder is for emergency use only in case of malfunction of the primary source of oxygen for long term oxygen therapy or power failure at the property and should not be used for any other use. Patients are advised to revert to the back-up oxygen cylinder in the event of a problem with the oxygen concentrator. This is further set out in the oxygen concentrator equipment guide at page 9 and the home oxygen cylinder equipment guide at page 11. Patients are also provided with BOC’s Patient Service Centre emergency contact details. The telephone number is a freephone number and is open 24 hours per day, every day of the year. The emergency telephone number is printed both within the equipment guides, and is also clearly visible on the oxygen concentrators themselves. After installation of the oxygen concentrator by BOC, over the ensuing 18 months, several visits to this patient’s home were made to cover such events as replenishment of cylinders, risk assessments and attendance on faults reported. BOC records all calls made to our Patients Service Centre and all activities are logged for full traceability and for audit purposes. Please find below our verbatim record of calls and activity relevant to this patient. 26.7,13 First next day HOOF (Home Oxygen Order Form) received (daughter had problems understanding advisor, repeating questions that were being asked) ward contacted Husband agreed to stay in for delivery 2213 Installation and training completed 1x machine 1xDF (back up cylinder) 4xDD (ambulatory cylinder). Equipment instruction material left with patient. 30.7.13 Respiratory nurse called checking current prescription 01.08.13 Fixed tubing installation completed to reduce risk of trips and falls 09.08.13 BOC tried to contact patient to do follow up call but no reply 21.08.13 Respiratory nurse called checking current prescription 22.08.13 New HOOF sent for increase in HPD Hour per Minute, new prescription, called patient and advised, no visit required, fax back sent 22.10.13 Machine serviced and RA (risk assessment) completed 14,11,13 Visit for Ambulatory cylinders replenishment 10.1.14 Visit for Ambulatory cylinders replenishment 24.1.14 Husband called to advise oxygen appeared to be coming through cannula too quickly and was louder than usual, PSR (patient service representative) attended same day BOC Limited, a mamber of The Lind 06.05.14 Machine serviced and Risk Assessment completed with portable replenishment 20.05.14 Husband advised whilst changing mattress he had caught the main tubing to switch for tap system, no flow, went onto back up cylinder and PSR attended within 4hrs 22,05.14 Visit for Ambulatory cylinders replenishment 03.08.14 Husband called and advised machine was loud, stopped working, ball at zero tried to troubleshoot on call but unsuccessful, went onto back up cylinder, PSR attended within 4hrs 09.11.14 Machine serviced and Risk Assessment completed 28.11.14 Respiratory nurse called checking current prescription 28.11.14 Husband advised patient deceased 27.11.14 call plan and charges stopped, collection of equipment agreed for 1.12.14 In dealing with this patient, BOC has followed its robust processes and procedures, and is in compliance with the terms of its contract with North East NHS. The oxygen equipment was checked at the required regular intervals and all necessary risk assessments were carried out in line with BOC's contractual obligations. In the particular instance of this patient and the power failure, BOC was not contacted by the patient or a family member at the time of the power failure - had BOC been contacted, the advice given would have been for this patient to use the back-up oxygen cylinder supplied by BOC until power was reconnected. BOC would then have made a visit to replenish the back-up oxygen cylinder. BOC is unsure as to the reason why this patient did not switch to her back-up oxygen cylinder for her oxygen supply when the power cut was detected, nor why she did not call for assistance. All the oxygen equipment removed from the property following the death of this patient was checked and found to be in perfect working order, including the concentrator, the back-up oxygen cylinders as well as all the ambulatory cylinders. Following BOC’s comprehensive review of its policies and procedures in respect of the supply of oxygen concentrators and BOC’s actions in respect of the current incident, BOC sees no reason at present to take any further action. BOC shall however continue to monitor its current procedures and make any adjustments and improvements as necessary. If you have any further queries or comments, BOC would be happy to address these — please contact me on Yours sincerel Business Manager — Homecare, BOC Healthcare. For and on behalf of BOC Limited
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