Woman died after being hooked up to an empty oxygen canister
An 84-year-old woman with advanced lung disease, who was dependent on oxygen, died after being hooked up to an empty canister, an inquest heard.
Joan Ross, who lived in Northleigh Avenue, Weston-super-Mare, died on November 7, 2011 during a stay at Weston General Hospital.
She had been admitted on October 18 due to continued breathlessness and a reliance on “oxygen therapy”.
The inquest, held yesterday at Flax Bourton Coroner’s Court, heard that Ms Ross, a retired school teacher, had a fall on the morning of her death, after asking to use the toilet.
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Later in the day she asked to use a commode and student nurse Claire Stoney helped her onto it.
Giving evidence, Ms Stoney said that due to where the commode was, she could not hook Ms Ross up to a wall supply of oxygen and so connected her to a portable canister.
Asked by deputy coroner Gail Elliman whether she had checked if there was any oxygen in the canister, she replied that she had not.
Another student nurse, Danielle White, said she later heard Ms Ross’s call bell and went to help her. Ms Ross told the student that she was short of breath and that she had a pain in the left side of her chest.
A staff nurse was called and physiotherapist Laura Burt, who was nearby, went to help.
Ms Burt told the inquest she knew the pensioner was dependent on oxygen and checked the canister, finding it to be empty. She connected Ms Ross to another canister, which discharged a high flow of oxygen – nine litres per minute.
Ms Burt said that Ms Ross seemed to be getting better but quickly became unresponsive.
Doctors arrived and tried to help Ms Ross but were told to stop by the hospital’s medical registrar, as a “do not resuscitate” instruction had been placed on her file.
The inquest heard that Ms Ross’s family had not known about this instruction and that there was no documentation to prove it had been discussed with either Ms Ross or her family.
Parts of a report into Ms Ross’s death written by Dr Goldman, consultant respiratory physician at Weston General Hospital, were read out.
He concluded that due to her diagnosis of advanced lung disease in 2006 and her deteriorating condition following the fall on the day of her death, Ms Ross would have been likely to die without the deprivation of oxygen.
He also said it was impossible to say how long she had gone without oxygen, and that it had only “hastened her demise”. He concluded that the medical cause of death was lung disease.
Ms Elliman said she agreed with the report and gave a verdict of natural causes.
A hospital spokeswoman said: “The trust would like to offer sincere condolences to Ms Ross’s family.
“We carried out an investigation into these circumstances and have put processes in place to make sure portable oxygen supplies are appropriately used.”