Whose job was it to turn on the oxygen?

SINGAPORE - Mount Elizabeth Novena Hospital is a short drive away from Tan Tock Seng Hospital (TTSH), but those few minutes claimed the life of an elderly patient who was being transferred between the two hospitals.

Ramasamy Krishnama died from a lack of oxygen to her brain after a three-man transfer team did not turn on the oxygen tank after putting her on a ventilator on July 8.

State Coroner Marvin Bay said yesterday that because there is no protocol that states what each staff member's responsibility is, "there is a potential hazard that team members may assume that the other is performing a task that is not in fact being undertaken".

The staff thought that the portable ventilator and oxygen tank were connected. Three to four minutes had passed before a nurse realised what was wrong and turned on the oxygen cylinder switch.

Madam Ramasamy's condition did not improve even after the ventilator was turned to the maximum setting and she was moved back to her TTSH bed. She was pronounced dead that evening due to the lack of oxygen to the brain.

"All eyes should be on either the patient or the devices monitoring vital signs, rather than on other subsidiary tasks," said Coroner Bay, as he called for "sufficient procedural safeguards" to be explored to avoid such tragedies.

He said that in such situations, the patient is too frail to indicate that he or she is in distress.

"They are therefore utterly dependent on the vigilance of the doctors and nurses of the transfer teams to spot if anything is amiss."

He advised that the ventilation equipment be retested at the actual site of the transfer during a non-emergency setting.

He also suggested a review of transfer protocols and that there be an overlap period for "the most critical moments" so that the sending team remains close to help the receiving team if needed.

Madam Ramasamy's transfer team had included one doctor and two nurses from Gleneagles and Mount Elizabeth Novena hospitals, both of which share the same parent company, Parkway Shenton.

Khor Chin Kee, Parkway Shenton chief executive, said yesterday that the health-care provider takes a very serious view of this incident.

"We have since reviewed and revised our protocols which address the issues raised... We will also see how to implement the coroner's recommendation to better coordinate with the sending hospital... for transfer cases," said Dr Khor.

gurveenk@sph.com.sg

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