Incident Happened After Coroner Had Previously Raised Concerns Following Another Patient's Death

A family have called for extra staff training after it was revealed a pensioner became the second patient to die at a hospital in a year after not being provided with oxygen during a ward transfer.

Ronald Burns, 84, was admitted to A&E at Sheffield’s Northern General Hospital with chest problems on 14 March, 2017. Following treatment, his condition improved and arrangements were made for him to be moved to the coronary care unit.

However, an inquest into his death held at Sheffield’s Medico-Legal Centre was told that upon arrival at the coronary care unit his condition had deteriorated significantly. A subsequent investigation revealed that a portable oxygen cylinder had not been turned on during the transfer. Ronald died four days later on 18 March, 2017.

Following the death of the father-of-two of Intake, Sheffield, Ronald’s family instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the care he received by Sheffield Teaching Hospitals NHS Foundation Trust, when he was a patient at Northern General Hospital.

Investigations have revealed that six people, including two at Northern General, died in three years after staff had accidentally not administered oxygen to patients during transfers. Around 400 similar incidents where patients had not died were recorded across the country in the same period.

Following the death of a patient, who did not receive oxygen during a ward transfer at Northern General in March 2016, a coroner issued a Preventing Future Deaths Report raising concerns that she believed future deaths could occur in similar circumstances unless action was taken.

Ronald’s family, including wife Connie, aged 88, and their children, Craig and Dawn, aged 54 and 58, have now urged Hospital Trusts across the country to learn lessons from his case. It comes after a coroner recorded a conclusion that the failure to provide oxygen during the transfer contributed to Ronald’s death.

Expert Opinion

“Ronald was a devoted, husband, dad, granddad and great-grandfather and all his family are still devastated by his death.

“The past months have been incredibly difficult for Ronald’s family, but we are thankful to the coroner for providing the family with the vital answers they needed with regards to Ronald’s death.

“During the course of our investigations it was established that it was the second time in just over 12 months a patient had died at Northern General Hospital after a portable oxygen tank was not switched on during the ward transfer of a patient.

“This combined with the fact there has been more than 400 other incidents across the country over three years is incredibly worrying. We believe this highlights a lack of training among staff. Therefore it is vital hospital trusts take swift action to put appropriate measures in place to ensure that a repeat of these incidents does not happen again.

“Ronald’s death and the inquest findings are an important reminder that the NHS must always put patient safety first.” Tania Harrison - Partner

After the hearing Craig, said: “Our family is angry and upset by the way the hospital treated Dad, particularly as we were not told about the incident with the oxygen until several days after his death. To then find out that something similar had previously happened was unbelievable.

“The inquest has been a very difficult time for us and it has been hard to once again hear of the issues that Dad faced in his care.

“Problems like this are unacceptable and while nothing will ever change what has happened, we are glad that the failings have been highlighted by the Coroner and steps are being taken to ensure issues of this nature are never allowed to happen again.

“You place great faith and trust in the NHS to provide a quality standard of care, so it is desperately sad to think that Dad did not get that.”

Dawn added: “I am deeply saddened and upset not only about what has happened to Dad but also the manner in which the hospital have responded. 

“It is difficult not to feel that someone has taken what little time we had left with him away from us all.  Dad paid the ultimate price for a careless mistake.

“The fact that the hospital chose to conceal this from us throughout upsets me even more. To find out about the potential hospital error from the Coroner’s office was a huge shock for our family.  It simply should not have happened that way.”

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Background

Ronald was married to Connie, aged 88, for 61 years. The couple had two children, Craig and Dawn, aged 54 and 58, as well as six grandchildren and three great-children.

The inquest heard that, Ronald, a former self-employed builder, had been admitted by ambulance to the Northern General Hospital on 14 March, 2017, with breathing difficulties and signs of a chest infection.

Following initial treatment in A&E, Ronald was taken to a resuscitation area and commenced on oxygen. His condition improved and he was transferred to the coronary care unit.  Upon arrival at the coronary care unit it was noted that his condition had deteriorated significantly and he was noted to be in peri-arrest – the sign that a cardiac arrest is imminent.

An internal report into Ronald’s death found that the A&E nurse who transferred Ronald did not recall checking his clinical observations prior to transfer nor could she recall checking that his mask and bag were being inflated by oxygen. On arrival at the coronary care unit, a nurse said the portable monitor was alarming and the oxygen cylinder had not been turned on.

Discussing the case, HM Senior Coroner, Christopher Dorries said: “It is deeply upsetting that the circumstances surrounding the death of Mr Burns bears such a similarity to circumstances of an earlier death upon which a Regulation 28 Report was generated. 

“It is also concerning that whilst a Datix entry was made about the incident there was never disclosure of the circumstances to the family nor (seemingly) to the doctors treating Mr Burns.”

He recorded a narrative conclusion that: “Mr Ronald Burns died in the Northern General Hospital, Sheffield on the 18th March, 2017.  He had been admitted on the 14th March in a serious condition arising from natural cause.

“Mr Burns showed signs of improvement in the Emergency Department and was then transferred to the cardiac care unit.  Unfortunately, during this transit his oxygen supply was not appropriately connected and he was deprived of the additional oxygen that he was intended to have and needed.  During the transfer the portable monitor was not placed in a position that the accompanying nurse could observe. 

“On arrival in the CCU Mr Burns showed a marked deterioration and the Court finds that this was due, in significant part at least, to the diminished oxygen provision.  On the basis of expert evidence his death was contributed to by this event.”

An inquest in October 2016 had heard that Simon Harper had died that March after he did receive oxygen during a ward transfer at Northern General. Following the hearing’s conclusion Louise Slater, assistant coroner for South Yorkshire issued a Preventing Future Deaths report. She wrote to then Health Secretary Jeremy Hunt asking him to consider providing training for staff in using portable oxygen cylinders.

Supplying oxygen to patients being transferred was switched in November 2010 from porters to nurses. The report said that one training session was provided to a small number of nursing staff at the time, after which the hospital relied on 'peer to peer' training.

A copy of the report was also sent to Sheffield Teaching Hospitals NHS Foundation Trust

A report from NHS Improvement in January this year revealed that between January 2015 and October 2017 six patients had died when hospital staff accidentally switched off their oxygen cylinders.

Further investigations uncovered 400 similar incidents - including 24 cases where patients came to “Severe or moderate harm”.

Most staff believed the cylinder was empty or faulty, however investigations, highlighted that staff were incorrectly operating the tanks and appeared to be confused by their design.