Connor Adrian Turner · Prevention of Future Deaths report

On 28th February 2013 I commenced an investigation into the death of Connor Adrian Turner, aged three months. The investigation concluded at the end of the inquest on 2nd February 2015. The cause of death being: 1(a) Unascertained and 2. Cystic fibrosis with previous laparotomy for meconium ileus and previous corrective surgery for congenital cardiac anomaly. The conclusion of the inquest was: Connor Adrian Turner was born on 14th November 2012 with cystic fibrosis and a congenital heart defect which was repaired on 14th January 2013. Connor subsequently developed cardiac arrhythmias and a paralysed right hemidiaphragm. Connor also suffered reflux and possible aspiration. He suffered recurrent chest infections. He was oxygen dependent and required an oxygen supply via a nasal cannula and cylinder. The cause of death could not be established.
Between 15:20 and 17:00 hours on 28th February 2013 Connor was not supplied with oxygen from the cylinder. The poor response to resuscitation, profound acidosis and high lactate and the severity of the damage sustained are all compatible with a hypoxic induced cardiorespiratory arrest. Connor’s observations would suggest that he did not have an acute respiratory infection. It is unlikely that reflux and aspiration were the cause of the cardiorespiratory arrest. On the balance of probabilities the cause of death could not be established but the lack of oxygen was a contributory factor.
Connor Adrian Turner died on 28th February 2013 at The General Infirmary, Leeds at 00:30 hours.

Connor Adrian Turner was born on 14th November 2012 with cystic fibrosis and a meconium ileus. The latter condition was operated on numerous occasions, the last of which was on 30th January 2013. Connor had a large ventricular septal defect and patent ductus arteriosus and an overarching aorta which was repaired on 14th January 2013. This baby also suffered from reflux and aspiration and was fed with a nasogastric tube. Connor was recovering from Pseudo Bartas syndrome and required oxygen through a nasal cannula. When he was taken out of the hospital he required a portable oxygen cylinder.
On 27th February 2013 Connor’s parents took him shopping in Leeds city centre. His oxygen tank was noted to be on and working before they left the hospital. Connor and his parents were in the Primark store when his mother noticed he had changed colour and had stopped breathing. Cardio pulmonary resuscitation was carried out. Paramedics attended. The Paramedic noticed that the oxygen cylinder valve was in the “off” position. Connor was then taken by ambulance to The General Infirmary at Leeds, where despite all efforts his death was confirmed at 0030 hours on 28th February 2013.

(1) There is no system in place for nursing staff to instruct and train parents and carers in the transfer of the oxygen supply from the main supply to a portable oxygen cylinder.
(2) That parents and carers should be initially supervised in forming this task until they are deemed to be competent to do so.
(3) That when a transfer has been made in preparation for the patient leaving the hospital, albeit temporarily, the patient should not be allowed to leave until an independent check has been made and all concerned are satisfied that the apparatus is functioning correctly and that those taking the patient out of hospital are competent to use the apparatus and that the appropriate reference to this should be made in the case notes.