Safeguards needed when transferring patients dependent on ventilation equipment: State Coroner

PHOTO: Safeguards needed when transferring patients dependent on ventilation equipment: State Coroner

SINGAPORE - These include closely monitoring the patient and devices tracking his vital signs when he is placed on the equipment, instead of other "subsidiary" tasks, and retesting the machine on-site beforehand.


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Oxygen tank not turned on, then patient dies by Ian Poh, published in The Straits Times, July 17

SINGAPORE - A grandmother died from a lack of oxygen to her brain after staff transferring her from one hospital to another did not turn on the oxygen tank after putting her on a ventilator.

Madam Ramasamy Krishnama became unresponsive in the three to four minutes that passed before the oxygen was turned on, a coroner's inquiry heard yesterday. No foul play is suspected.

The 83-year-old, who had been warded in June last year at Tan Tock Seng Hospital following a heart attack, was being transferred to Mount Elizabeth Novena Hospital when the incident took place about a month later.

Madam Ramasamy, who had become dependent on mechanical ventilation, died a few hours after her condition deteriorated owing to "ventilatory failure" that cut off her oxygen supply.

A police investigation report submitted to the court noted that her vital signs had been stable hours before the incident. She had also been alert and comfortable before being handed over to the receiving team.

This comprised a doctor and nurse from Gleneagles Hospital - which shares a parent company, Parkway Shenton, with Mount Elizabeth Novena Hospital - and a staff nurse from Mount Elizabeth Novena Hospital.

But shortly after being transferred from her bed to a trolley and put on a portable ventilator on July 8 last year, Madam Ramasamy's level of oxygen saturation was noted to be "unrecordable", raising concerns that it was very low.

This led the transfer team to check their equipment. One of the nurses realised that a switch on the portable oxygen tank used to supply the portable ventilator had not been turned on.

The oxygen cylinder switch was then turned on and the ventilator turned up to the maximum setting, but Madam Ramasamy's condition did not improve, the inquiry heard. She was moved back to her bed, where cardiopulmonary resuscitation was attempted on her, but to no avail. She was pronounced dead at 9.55pm the same day.

Next   Next   'Would have expired even with the best treatment'

The patient, who had a heart attack on June 13 last year, had a history of diabetes, high blood pressure and excessive levels of fatty substances in the blood, known as hyperlipidemia. Citing the attack and other complications, a medical report mentioned in the police report said her heart, which could not be restarted after she went into cardiac arrest during the incident, was "the major problem".

Given her poor health and critical state at the time, the short period of oxygen deprivation had "probably precipitated" her death, said the report.

It added that she "would have expired in the very near future even with the best treatment".

According to an internal review conducted by Parkway Shenton, the transfer team had assumed that the switch was already turned on as staff had heard air gushing out when the ventilator was connected to the oxygen tank. They thus checked the equipment for other problems first, not immediately realising that the cylinder switch was not on.

Madam Ramasamy left behind six children and more than 10 grandchildren.

Her family said through their lawyer Tan Hee Joek that they were deeply saddened by her loss and await the findings of State Coroner Marvin Bay. These will be delivered on July 30.

pohian@sph.com.sg


This article was first published on July 15, 2014.
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