Description
In terms of s.6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that John Aitken died within ward 14 at Dumfries and Galloway Royal Infirmary (DGRI), Dumfries on 1 April 2009 at 18.00 hours. In terms of s.6(1)(b), the cause of death was (a) Cardiorespiratory arrest (b) Hypoxic brain damage and (c) Widespread severe bronchopneumonia. Formal determinations were made under s.6(1)(c) and (d).
Background
The deceased had experienced problems with his oesophagus since 1997. In July 2008 a tumour was discovered. An endoscopic examination was carried out which resulted in an oesophageal perforation, a common complication of the procedure. Mr Aiken underwent further surgery a few days later. He developed a complication whereby his lower limbs became paralysed. He was transferred to the Acute Rehabilitation Ward (ward 14) in August 2008. By March 2009 his condition had worsened and a decision was taken to transfer him to the Intensive Care Unit (ICU).
An ICU doctor had instructed that Mr Aitken's blood saturation levels be continuously monitored before and during the transfer. Nursing staff did not record this instruction on medical notes. They were unable to find a blood monitoring machine so carried out the transfer without one. Mr Aiken was provided with an oxygen mask and cylinder during the transfer. It is unclear whether the oxygen supply was switched on. Staff moved Mr Aitken from the ward towards the lift. They then noticed that he did not look well and rushed him back to ward 14. When doctors arrived Mr Aitken had no pulse and was not breathing. Resuscitation was not performed in light of a previous “Do Not Resuscitate” instruction.
Determination
In terms of s.6(1)(c) there were a number of reasonable precautions which could have been been taken to avoid the death. Medical instructions regarding blood saturation levels should have been recorded in nursing notes. The levels should have been closely monitored before and during the transfer to ICU. Mr Aitken's ICU doctor should have been informed that there was no machine available to monitor levels during the transfer.
In terms of s.6(1)(d) there were a number of defects in the system of working which contributed to the death. At the time of the death there was no formal policy for the care of patients during ward transfers. Blood levels and other information was not recorded on Mr. Aitken's chart prior to transfer. Blood levels were not monitored during the transfer and Mr Aitken did not receive oxygen during the transfer. Staff lacked adequate training in the requirements for the transfer of ill patients.
