Mr Matthews · Prevention of Future Deaths report

On 1 May 2016 I commenced an investigation into the death of Mr Matthews, born 6th May 1938. The investigation concluded at the end of the inquest on 20 July 2016. The conclusion of the inquest was that Mr Matthews died on 19th February 2016 from Pneumoconiosis which was probably the predominant cause of the COPD and that his pneumonia was a significant contributory cause.

The original referral to the Coroner had been because Mr Matthews had been a miner (coal face worker). He had a history of COPD and had been admitted to hospital with an exacerbation of his COPD. An oxygen mask had sufficed and he was subsequently discharged to a care home. The following day he was found collapsed in his room and after initial treatment he was transferred to hospital. He had a cardiac arrest in the ambulance and was successfully resuscitated. On arrival at hospital he was admitted to the acute medical unit. He was treated with antibiotics and steroids and was reviewed by a respiratory consultant who felt that his condition was improving and he could be discharged home. On the day of his proposed discharge, he was found unresponsive in bed. He was taken to the emergency department and shortly after arrival suffered a further cardiac arrest. He was resuscitated, admitted to the medical ward and died later that day. A post mortem was carried out and the cause of death was found to be Pneumoconiosis, COPD and pneumonia. The circumstances of his death were reviewed by the Trust and a number of issues were raised which led to this report being submitted.

(1) Mr Matthews died of Pneumoconiosis. He had worked as a miner for 32 years and a further 10 years at a coal mine. He had been diagnosed with COPD in May 2016. Checks had been conducted by the Respiratory ward. Since the incident I have been provided by the NHS Foundation Trust with a report into the incident and a review of the Trust's policies and procedures. The Trust has introduced a new policy for oxygen prescribing and has reviewed its policy for the use of oxygen. The Trust has also reviewed its policies in relation to the use of oxygen cylinders and oxygen concentrators. The Trust has also reviewed its policy for the use of oxygen cylinders and oxygen concentrators.

(2) Notwithstanding the conclusion of the manufactuer that the oxygen was still being delivered by the device in the right concentration, I am concerned that there was no system in place to ensure that the oxygen was being administered at the prescribed rate. An oxygen concentrator had been set up for use by the patient and the flow rate had been set at 2 litres per minute. The Trust's policy states that all oxygen must be prescribed and the prescribed rate should be recorded on the drug chart. The oxygen was not prescribed on the drug chart and the flow rate was not recorded. This meant that staff were unaware of the prescribed rate and there was no means of checking that the concentrator was delivering the prescribed flow rate.

(3) The Trust's policy for oxygen states that oxygen must be prescribed and that the prescribed rate should be recorded on the drug chart. However, no such prescription was made in the drug chart and no record was made of the flow rate.

(4) The Clinical Engineering Team Leader and the manufacturer concur that the damage to the oxygen concentrator was caused by an accident and that the damage was not responsible for the death. Nevertheless, I am concerned that the incident was not reported to the manufacturer at the time and that no investigation was carried out. The Trust has subsequently reviewed its incident reporting policy and the manufacturer has reviewed its own policy.

(5) There was no system in place to ensure that the oxygen concentrator was working correctly. It does not state precisely how to check the amount of oxygen delivered by the device, nor does it state what action should be taken if the device is not working correctly.