Mrs Lynn Hadley · Prevention of Future Deaths report

On the 23 April 2020, I commenced an investigation into the death of Mrs Lynn Hadley. The investigation concluded at the end of the jury inquest on the 12 November 2020. The conclusion of the inquest was a short form conclusion of accidental death.

The cause of death was:

1a Fatal Burn Injuries Incompatible with Life

i) On the 13 April 2020, paramedics attended Mrs Hadley’s home address. She had been complaining of COVID-19 type symptoms. On examination it was determined that she needed oxygen therapy. The oxygen cylinder was taken out of the Basic Life Support (BLS) bag, and the protective celophane removed. The tubing was attached to the cylinder and turned on to deliver 4 litres.

ii) The cylinder then sparked and then set alight from the collar region and set the house on fire.

iii) Mrs Hadley was located on the ground floor to the rear of the property and the house caught fire very quickly. Despite efforts from family members and paramedics, they were unable to remove her from the property.

iv) Sadly, Mrs Hadley died from her burn injuries.

1. Evidence emerged during the inquest from two destructive examinations of the damaged regulator indicated that ignition happened following either adiabatic compression or particle impact. Either of these two events occurred within the on/off shuttle cartridge assembly of the brass regulator which was attached to an oxygen cylinder used to treat Mrs Hadley.

2. Although both of these phenomena are extremely rare, the sudden uncontrolled release of oxygen by rapidly opening the on/off valve of the regulator can expedite the occurrence of ignition.

3. Evidence from the paramedic confirmed that she opened the patient valve first before opening the on/off valve, thus increasing the chance of the reported phenomena occurring.

4. Evidence from the Fire Investigation Officer, confirmed that there was little if any knowledge of either adiabatic compression or particle impact and the ramifications of such an event when opening a cylinder incorrectly by those responsible for using the equipment.

5. Evidence from the MHRA confirmed that they are aware of four cases of ignition within valve components of oxygen cylinders leading to fire since 2011 including this incident. The valve manufacturer VTI, Germany has subsequently reported nine cases of ignition. VTI are also examining a further 20 regulators. At present no defects have been found.