SINGAPORE - An elderly patient died because of "medical misadventure", a coroner's inquiry found yesterday, after a transfer team failed to ensure that her ventilation equipment was working properly when moving her between hospitals.
State Coroner Marvin Bay called for stricter procedural safeguards to be put in place after recording how 83-year-old Madam Ramasamy Krishnama died while being transferred from Tan Tock Seng Hospital (TTSH) to Mount Elizabeth Novena Hospital on July 8 last year.
Shortly after being moved from her bed to a trolley and put on a portable ventilator, her level of oxygen saturation became "unrecordable" as the transfer team had failed to turn on an oxygen tank supplying the ventilator.
The staff did not immediately realise this as they were checking for other problems.
They had assumed the tank had been switched on after hearing a gushing sound when the two pieces of equipment were connected.
They eventually switched the supply on three to four minutes after putting Madam Ramasamy on the ventilator, but it was too late for the grandmother, whose condition did not improve even after the ventilator was turned to the maximum setting.
She was moved back to her bed, where cardiopulmonary resuscitation was attempted, unsuccessfully. She died from a lack of oxygen to the brain later that day.
On Wednesday, Coroner Bay found that Madam Ramasamy's death had been caused by the failure to ensure that she received sufficient ventilation. No foul play is suspected.
He called for a review of transfer protocol, suggesting there be an "overlapping period" when sending teams remain on standby to help the receiving team during the critical moments of the transfer. This was not done in Madam Ramasamy's case.
He also recommended that medical staff test ventilation machines on site before use when it is not an emergency.
Coroner Bay said many patients in Madam Ramasamy's situation would be too frail to say or gesture if they are in distress. "They are... utterly dependent on the vigilance of the doctors and nurses of the transfer teams to spot if anything is amiss."
The transfer team in Madam Ramasamy's case, which comprised a doctor and two nurses, was put together by Parkway Shenton, which shares the same parent company as Mount Elizabeth Novena Hospital.
Madam Ramasamy had a history of health problems before suffering a heart attack on June 13 last year, which led to her hospitalisation at TTSH. She left six children and more than 10 grandchildren.
In a statement yesterday, Parkway Shenton chief executive Khor Chin Kee said the firm was "deeply sorry" for her family's loss and has been providing support and assistance. He said the matter has been resolved but the firm would continue to give help where possible.
Dr Khor added that Parkway Shenton took a serious view of the incident, and has reviewed and revised the relevant protocols. "We will also see how to implement the coroner's recommendation to better coordinate with the sending hospital... for transfer cases," he said.
Approached after the hearing, Madam Ramasamy's 47-year-old daughter, Ms Bachant Kaur, said she was "OK" with the findings but declined to comment on whether any legal action has been taken against Parkway Shenton. "The way my mother died is very painful for me and my family. We hope that it will not happen again," she said.
This article was first published on July 31, 2014.
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