Mr Simon Timothy Harper · Prevention of Future Deaths report

On 15th March 2016 I commenced an investigation into the death of Mr Simon Timothy Harper. The investigation concluded at the end of the inquest on 28th October 2016. The conclusion of the inquest was that Mr Simon Timothy Harper died from;

1a) Multiple Organ Failure
1b) Pneumonia
1c) Alcohol related liver disease

A narrative conclusion was recorded as follows:

Mr Harper was admitted to the Northern General Hospital on the 6th March 2016 with jaundice and abdominal distention. His condition deteriorated and he was transferred to the intensive care unit on the 7th March 2016. However, during the transfer Mr Harper’s oxygen cylinder was not turned on and it is likely this lead to him suffering a cardiac arrest whilst on route.

Mr Harper was successfully resuscitated but he continued to deteriorate and died on the 9th March 2016. It is not possible to state what effect, if any, this cardiac arrest has had on Mr Harper’s death.

Mr Harper was admitted to the Northern General Hospital on 6th March 2016 with jaundice and abdominal distention. On the 7th March 2016, Mr Harper suffered liver failure, kidney failure and respiratory failure. Mr Harper was receiving oxygen via a non-rebreathe mask from the main hospital wall supply to support his lung function. Later that evening the patient underwent a Critical Care Review who agreed a transfer to the General Intensive Care Unit. In order to transfer Mr Harper safely a portable oxygen supply was required and this was supplied by the portering department. It is the responsibility of nursing staff to connect the cylinder to Mr Harper. On route to the General Intensive Care Unit the patient, Mr Harper suffered a sudden deterioration and it was noticed that the portable oxygen cylinder had not been turned on. Mr Harper suffered a cardiorespiratory arrest to which resuscitation attempts were successful. He was admitted to the General Intensive Care Unit shortly after midnight at which point he was deeply comatose and anuric. On 9th March 2016 treatment was withdrawn and death occurred at 1800.

The inquest heard that in November 2010 the act of connecting a patient to an oxygen cylinder for transfer was reassigned from porter staff to nursing staff.

Upon the reassignment of the task, one session of training was provided by an external company to a small number of nursing staff who were on duty at the time. There is no record regarding the contents of the induction/training or who was present at the time. In addition, the Trust confirmed that since that date there has been no formal training and they have relied on ‘peer to peer’ training. In addition, no register of individuals trained or content of training is documented. There is no record of who has and has not received relevant training and no audit is in place to assess the appropriateness of this ‘on the job’ his training.

The inquest heard that the nurse responsible for connecting the patient to the oxygen cylinder did not turn the valve to allow oxygen flow. It is probably that this lead to the cardiorespiratory arrest although it was accepted no-one could be certain of this.

The Secretary of State for Health is asked to consider whether it is appropriate for training to be provided and documented regarding the use of portable oxygen cylinders for patients. The implementation of a Transfer of Patients Policy should also be considered as those available did not cover this issue.