Kentish Gazette Canterbury & District
Tragedy as nurses couldn’t hear alarm
Intensive care nurses were unaware a patient who later died had stopped breathing because the volume on a machine monitoring his vital signs had not been turned up. Christopher Osland, 65, was being treated in the critical care unit at Kent and Canterbury Hospital when his oxygen levels plummeted, triggering an automatic alarm.
But the monitor’s volume had not been set at a loud enough level to be heard outside the room, and the device had also become disconnected from a central system which would have alerted staff at a nurses’ station.
It meant a delay of up to 10 minutes before medics realised something was wrong - by which time Mr Osland had suffered catastrophic brain damage.
He did not regain consciousness and died 16 days later. An inquest into his death was told he had been admitted to the K&C on March 30 last year after suffering a stroke.
Two days later he went into cardiac arrest and was moved to the hospital’s intensive care unit, where he was put on a
life-support machine.
His condition slowly improved, so he was gradually weaned off the machine for three hours at a time.
But on April 26 - during a 10-minute changeover of nursing staff - his oxygen levels started to fall for reasons that have never been established. This sudden change triggered an alarm that could not be heard outside the room, and no alert was sounded at the nurses’ station.
Investigations after Mr Osland’s death revealed the volume on the machine monitoring his oxygen levels had not been increased to a level audible outside the room.
It was also found that the room monitor had become disconnected from the central monitor - known as going OFF COMS - one week before, on April 19. An alert informing staff of this had been silenced on the same day, the coroner presumed, but there was no evidence that action had been taken to ensure the connection was restored despite a warning displaying on the screen of the central monitor for five days.
At an inquest held before a jury, Mr Osland’s cause of death was given as hypoxic ischaemic encephalopathy - a brain injury caused by oxygen deprivation. Assistant coroner Kate Thomas said: “The evidence at the inquest was that not all nurses knew that the sound level of alarms on room monitors could be reduced and so did not check alarm volume when coming on shift.”
Both units were working correctly, she found.
In a report to prevent future deaths sent to the East Kent trust, the assistant coroner raised several concerns about what was a new monitoring system.
Ms Thomas said: “Nursing staff are unaware that the room monitor volume could be reduced to the point where it was not audible outside the room - as a result, the volume of the room alarm was not part of handover equipment checks. “The circumstances in which the room monitor alerts were reduced were not documented, and accordingly subsequent staff would not be aware that they had been so reduced. “After silencing the OFF COMS alert on the central monitor, no steps were taken to ensure it was reconnected to the room monitor.
“No steps had been taken to respond to the OFF COMS notification on the central monitor screen, which had persisted for the five days prior to April 26. “It is unclear as to when the
OFF COMS disconnection between the room and central monitor would have been rectified had it not come to light after Mr Osland’s arrest.
“It was unclear what steps nurses were supposed to take when confronted with an OFF COMS alert or screen notification.
“In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.” The report to prevent future deaths was also forwarded to the Care Quality Commission, NHS England and Improvement, as well as Mr Osland’s son and widow.
Sarah Shingler, the chief nursing and midwifery officer at East Kent Hospitals, said: “Our thoughts are with the family and friends of Mr Osland and we are deeply sorry for the failings in his care.
“The coroner has acknowledged that we have made a number of changes to ensure this does not happen again, including improving training for staff, ensuring that handovers take place at a patient’s bedside and equipment is checked regularly. “We are responding to the coroner’s report and will make any further changes that are needed.”