An inquest into the death of a woman under the care of West Hertfordshire Teaching Hospitals NHS Trust began on Monday 20 January.
Cecilia Harper (71) died in Watford General Hospital on 9 February 2022, while being transported from her ward to the radiology department. She had been admitted to the hospital five days earlier.
The mother-of-two had reported breathlessness while in hospital, after initially being provided with oxygen via nasal cannula, her oxygen dependency increased and Cecilia was provided with an non-rebreather oxygen mask for the journey and was accompanied by a porter and student nurse. She was conscious when she left the ward, yet by the time she arrived in the ultrasound room she had lost consciousness. A number of medical staff undertook CPR but Cecilia had sadly died.
Upon investigation, it was discovered that Cecilia’s oxygen cylinder was empty, it was not clear when this occurred. During the first day of the inquest, it was heard that research carried out by a doctor at the Trust indicated that 10% of patients transferred to the A&E CT department have insufficient oxygen for a return journey, while 9% of patients made the journey with oxygen cylinders switched off.
However, a post-mortem report, which identified metastatic breast carcinoma as the cause of death, made no mention of the impact of the empty oxygen cylinder or oxygen dependency.
An inquest took place at the Coroner’s Office for the Area of Hertfordshire to determine the cause of Cecilia’s death. There have been two previous inquest review hearings to ensure all appropriate evidence has been sought, which has delayed proceedings.
The inquest, which was expected to take place over three days, concluded on Tuesday (21 January). The inquest sought to confirm the exact circumstances surrounding Cecilia’s death.
The coroner determined that Mrs Harper died from natural causes, but it is unclear whether there was any problem with oxygen supply, and it is unclear if there was a problem with oxygen supply, if it contributed to her death.
There was not a determinative finding because of the contradictory evidence and lack of documentary evidence relating to the timings of when things occurred.
Tees Law, acting for Cecilia’s family, has highlighted possible breaches in regulations by West Hertfordshire Teaching Hospitals NHS Trust.
Hospital staff have reported different times for the length of Cecilia’s journey from her ward to the ultrasound room, however it is understood to have taken at least six minutes. Moreover, it is believed to be contrary to best practice for a porter and a trainee nurse to accompany a patient in the way Cecilia was transported. Instead, she should have been accompanied by appropriately trained professionals.
Sophie Stuart of Tees, acting for the family, said: “These tragic events pose many questions about the use of oxygen cylinders for patients within West Hertfordshire Teaching Hospitals NHS Trust.
Cecilia’s family is hoping that the inquest will help shine a light on what happened to Cecilia. By highlighting any failings in her care, the family hope that the Trust will address a wider problem in order to ensure this never happens to any other patient.
It is also worth noting that NHS England issued Patient Safety Alerts in relation to oxygen cylinders in 2018 and 2023. Our concern is that despite these alerts this issue still seems to be a problem and could be affecting other patients."
Living in St Albans at the time of her death in her early 70s, Cecilia had many jobs throughout her life. Notably, she worked in Hong Kong, managing American expatriates in South-East Asia for the global technology firm IBM. She returned to the UK in 1983, where she lived ever since with her husband John.
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