NHS investigates deaths after oxygen cylinder mistakes
AN NHS investigation has been launched following the deaths of six patients after hospital staff accidentally switched off their oxygen cylinders.
A safety alert has been issued after watchdogs uncovered more than 400 incidents in which cylinder controls were wrongly operated – including 24 cases where patients came to “moderate or severe harm”.
The blunders saw six patients die, while five suffered cardiac arrest or stopped breathing and five were left unconscious. Incidents involved newborn babies, patients on resuscitation trolleys and those on cardiac units, a safety alert discloses.
NHS Improvement yesterday ordered all trusts to check that staff know how to operate the devices, and the Healthcare Safety Investigation Branch has opened an urgent investigation into the errors, some of which date back three years.
Watchdogs said the errors may have occurred because staff were unaware of a change in the design of the cylinders, leading them to believe oxygen is flowing when it is not.
Patient safety experts at NHS Improvement issued the warning after detecting 400 incidents reported to the national safety reporting system in the last three years.
Their alert states: “All deaths and severe and moderate harm incidents were reviewed and 24 incidents related to failure to operate the oxygen cylinder controls to obtain a flow of oxygen were identified.”
It adds: “Six patients died, although most were already critically ill and may not have survived even if their oxygen supply had been maintained.
“Five patients had a respiratory and/ or a cardiac arrest but were resuscitated, and four became unconscious.
“Other incident reports described patients experiencing difficulty breathing and low oxygen saturations that required urgent medical attention.”
The watchdog said cylinders had been redesigned in recent years in an attempt to improve safety, by introducing an extra step to reduce fire risks. But staff who were unaware of the changes may have thought oxygen was flowing when a key valve was switched off, the alert suggests. In other incidents, they may have been left unable to turn the oxygen flow on in an emergency, the report warns.
Even after blunders were made, most staff assumed the cylinder must have been faulty or empty, rather than realising their error, the alert found.
The investigation will focus on the design of portable oxygen delivery systems, supply and storage of oxygen cylinders to clinical areas and the design and delivery of training.
Dr Kathy Mclean, executive medical director at NHS Improvement, said: “It is vital that NHS staff are appropriately supported to correctly use these designs of oxygen cylinders.
“That’s why NHS Improvement is calling on all providers to take immediate action to determine if steps are needed to prevent these incidents and that action plans are under way to reduce this risk.”
The alert is aimed at NHS hospitals, which use oxygen for patients with respiratory and heart problems.
NHS Improvement raised concerns that the same errors may be being made by ambulance crews, or in care homes and GP practices. The watchdog also urged community services providing home oxygen services to also take note of the findings and ensure carers and staff had full training.