SINGAPORE - It was a basic task - ensure that the patient had oxygen to breathe while she was being transferred from one hospital to another.
But when the medical team heard a hissing sound, they mistook it to mean that the oxygen supply to the ventilator was switched on.
It wasn't, and they realised their mistake only three to four minutes later.
By then, Madam Ramasamy Krishnama, 83, was rapidly becoming unresponsive.
On Wednesday, state coroner Marvin Bay said this had caused Madam Krishnama, who was already frail from her history of medical problems, to "fall on a steady and irreversible downhill slide to her eventual death" in July last year.
As he presented the findings into her death, he called for a review of the relevant protocols during the transfer of a patient from one hospital to another.
He ruled out foul play and stated that she died from hypoxic brain injury, which occurs when the brain does not get sufficient oxygen.
In his findings, Mr Bay said that Madam Krishnama had suffered a heart attack on June 13 last year and was taken to Tan Tock Seng Hospital (TTSH).
She was warded for about a month, during which her condition fluctuated.
On July 8, her family decided to transfer her to Mount Elizabeth Novena Hospital (Mount E) for further care under a cardiologist.
Madam Krishnama's transfer was handled by Dr Adrian Wong, a senior resident physician from Gleneagles Hospital, which shares the same parent company as Mount E.
Dr Wong was assisted by Nurse Calangi Kathrina Iris Gayo and Nurse Bojilador Alex Romana.
Shortly after putting Madam Krishnama on a portable ventilator, the transfer team noticed her vital signs could not be read on the monitor, said the state coroner.
One of the nurses realised that a switch on the portable oxygen tank feeding the ventilator had not been switched on.
By then, Madam Krishnama had become unresponsive, he added.
She died hours later on the same day.
On Wednesday, Mr Bay questioned whether there were sufficient safeguard procedures in place during the transfer.
"In many such situations, the patient requiring mechanical ventilation is... utterly dependent on the vigilance of the doctors and nurses... to spot if anything is amiss," he said, adding that equipment should be checked on-site before a transfer.
"This would... ensure that the team is not taken by surprise or misled by unexpected developments or quirky events, such as the hiss of air which the team mistook to mean that the ventilator was providing oxygen."
While he noted that the team was highly trained and experienced, he highlighted his concern that each of the staff member had no clear individual tasking.
"There is a potential hazard that team members may assume that the other is performing a task that is not in fact being undertaken," he said.
He also said that as soon as the ventilator is placed on the patient, all eyes should be on the patient or devices monitoring the vital signs.
Mr Bay also suggested that the sending-off team from TTSH could have been close by to provide assistance.
"Rather than the three pairs of eyes that searched in vain for the critical three to four minutes ... three additional sets of eyes could have helped identify the mistake," he said.
He concluded that Madam Krishnama's death was caused by failure to ensure that she got sufficient oxygen, and he expressed his condolences to her family.
Parkway Shenton 'deeply sorry', revises protocols
Dr Khor Chin Kee, chief executive officer of Parkway Shenton, said: "We are deeply sorry for the family's loss. Since the incident, we have been providing support and assistance to the family."
Parkway Shenton was handling the transfer and is part of the healthcare chain with Mount Elizabeth Novena Hospital and Gleneagles Hospital.
Dr Khor added that the healthcare chain is taking a very serious view of the incident and has since reviewed and revised its protocols that address the relevant issues.
"We will also see how to implement the State Coroner's recommendation to better coordinate with the sending hospital - in this case, Tan Tock Seng Hospital - for transfer cases," he said.
Tan Tock Seng Hospital could not be reached for comment.
Family still grieves for great-grandma
Family still grieves for great-grandma
Madam Ramasamy Krishnama was well until her heart attack, said a 52-year-old family member.
"Even at her age, she could still run after the bus, but she was stopped by my sister," he recalled with a laugh.
Speaking to The New Paper from his home in Simei on Wednesday, he said Madam Krishnama was dearly missed by her extended family. The mother of six had 15 grandchildren and nine great-grandchildren.
She had never worked and she had spent her whole life taking care of her family. She was homely and enjoyed reading Indian epics until her eyesight started to fail, said the family member.
Madam Krishnama had a history of diabetes, high blood pressure and excessive levels of fatty substances in the blood.
On June 13 last year, she had been talking to her granddaughter when she suffered a heart attack.
Madam Krishnama, who would rotate her stay between her children's homes, was at her daughter's home in Hougang when it happened, said the family member. She was taken to Tan Tock Seng Hospital, where her condition was stabilised.
Trying to move on
A week later, she was well enough to be considered for discharge, only to have her condition worsen again on June 22 due to a high fever.
She was transferred to the high dependency unit and continued to show signs of heart failure, chest infection and respiratory failure. Her family decided to transfer her to Mount Elizabeth Novena Hospital.
Her daughter, Ms Bachant Kaur, 48, told reporters in court on Wednesday that it has been a year, but the family is still hurting from the manner of Madam Krishnama's death.
"I'm emotionally a bit down. The way my mother died was very painful for me and my family. Today, we are still fighting the pain," she said.
"We are trying to move on. We hope (such an incident) will not happen again."
The family member said that his mother's death had been a shock to all of them.
"All we wanted was for her to come back (from the hospital) safe and sound," he added.
- Additional reporting by Linette Heng
This article was first published on July 31, 2014. Get The New Paper for more stories.