Thomas William Browne · Prevention of Future Deaths report

A Coronial investigation was commenced on 20th July 2018 into the death of Thomas William Browne. The investigation concluded at the end of the inquest which I conducted on 25th November 2019. The conclusion was that the death occurred as a result of natural causes and the medical cause of death was 1 (a) Chronic Obstructive Airway Disease; 1(b) Corpulmonale; 2 Hypertension; Previous Myocardial Infarction

These were recorded as :-

Thomas William Browne, known as “Bill”, was found in a collapsed state in a toilet at ward 12, Prince Charles Hospital, Merthyr Tydfil at about 12.45 pm on 17th July 2018. He had been taken to the toilet by a nurse and left unaccompanied. His Oxygen supply cylinder was found exhausted when he was found.

The Inquest focused upon:-

a. The fact that Mr Browne was a highly vulnerable patient reliant upon non-invasive ventilation by Oxygen
b. He was taken to the lavatory by a member of nursing staff, using an Oxygen Cylinder said to have been found by her by his bedside.
c. The Nurse left him unaccompanied in the lavatory, did not inform any other member of staff that she had done so, and left the ward.
d. Mr Browne was found in a collapsed state in the lavatory approximately 45 minutes later
e. His Oxygen supply was exhausted when he was found.

(1) Although on the evidence at the Inquest, a finding was made that Mr Browne died from natural causes, the evidence gives rise to the concern that patients may be left unaccompanied while being dependent upon a finite supply of Oxygen, where no systems are in place for ensuring that they are monitored and assisted before such supplies run out.

(2) The root cause analysis was accepted in evidence by the Trust to be deficient in that it did not identify and address this issue.

(3) Training in the administration of Oxygen remains incomplete.

(4) There are no formal procedures for recording the time that the finite supply of Oxygen to patients will expire.