Jean Griffiths · Prevention of Future Deaths report

On the 27th of July 2017 I commenced an investigation into the death of Jean Griffiths aged 70 years. The investigation concluded at the end of the inquest on the 6th March 2018. The conclusion of the Inquest was:-

Natural Death

On the 15th July 2017 Jean Griffiths died at Salford Royal Hospital having displayed symptoms of Acute Interstitial Pneumonitis. Her oxygen lead was found to be disconnected at the time, but this did not contribute to her death.

1. In the course of the Inquest I heard evidence from ████████ who is a consultant in Respiratory Medicine at Salford Royal Foundation NHS Trust. ████████ referred in his evidence to the British Thoracic Society’s Emergency Oxygen Audit Report relating to a National Audit Period between the 15th August and the 1st November 2015.
2. ████████ stated that the Audit Report revealed a threat to patient safety due to poor prescribing practice in relation to the prescription of oxygen.
3. A key finding of the report was that 42.5% of patients receiving supplementary oxygen had no valid prescription. Without a valid prescription which includes a target range, ████████ stated that there was a danger that patients might be given too little oxygen or too much oxygen and thus be placed at risk of increased mortality.
4. A copy of the relevant Audit Report is attached.
5. ████████ evidence was that the pace of changing this poor prescribing practice needed to increase.
6. Although there was no evidence that Jean Griffiths’ lack of oxygen prescription was in any way causative of or contributory to her death nevertheless this report is submitted with a view to preventing the deaths of other patients who might be at risk.