Covid-19 patient died after respiratory equipment “was not closely monitored” – report
A Covid-19 patient has died in a room on the hospital side after his breathing equipment was disconnected and his calls for help were not heard, a new report suggests.
Health and safety officials have urged hospitals to ensure that patients in need of some type of respiratory support are closely monitored if they are being treated outside of critical or high-dependency units. .
The Health and Safety Investigations Directorate (HSIB) has reviewed the case of a 73-year-old man named only Terry who was admitted to hospital in December 2020 with Covid-19.
Despite receiving some oxygen, Terry’s oxygen levels continued to drop below acceptable levels, so the doctors decided to use continuous positive airway pressure (CPAP) – a form of Respiratory support used when a patient is awake and able to breathe on their own, typically administered via tubing and a mask or hood.
To avoid cross infection with other patients and staff, Terry was treated in a side room of a medical ward.
His condition was monitored and he was “regularly” seen by nurses from the nearby intensive care team, and Terry was also seen by an intensive care doctor.
On the evening of his second day at the hospital, Terry called for help using his call bell.
The HSIB said the department was “extremely busy” at the moment due to a staff shortage, a new patient arriving on the department and “competing clinical priorities”.
Her report added: “A nurse was putting on her personal protective equipment ready to enter Terry’s room and looked out the observation window.
“She could see Terry lying motionless on the floor. The CPAP machine and other alarms, which normally alerted staff to a potential problem, could not be heard outside the side room.
“Terry still had the CPAP mask on his face but the tube was disconnected. Terry did not respond to resuscitation attempts and died.
HSIB’s investigation highlights challenges faced during peaks of the crisis, including labor shortages and challenges in providing treatment outside of normal clinical areas.
HSIB said patients with Covid-19 who are treated with CPAP require close monitoring and observation.
“Caring for such critically ill patients in the general service side rooms poses a security risk,” he added.
He said there are staffing issues and other pressures associated with caring for these patients outside of intensive care or high dependency units.
Staff caring for Covid-19 patients requiring CPP in general wards need training and skills assessment to feel confident in providing care, the HSIB added.
He said hospitals should establish “respiratory support units” where nurses treat no more than four patients at a time.
Kathryn Whitehill, Senior National Researcher at HSIB, said: ‘The large number of Covid-19 patients requiring respiratory assistance meant that the NHS had to adapt and make the best use of its space and resources to respond to demand and minimize the risk of spread. infection.
“This has highlighted a safety risk outside of intensive care and high dependency areas and in particular for patients requiring respiratory support such as CPAP in side rooms of general wards.
“In a side room, alarms from the monitor cannot be heard and the patient and the monitoring equipment to which they are connected can only be seen if a healthcare professional is present at all times.
“This investigation highlights the tremendous pressure on staff and reminds the devastating impact of the pandemic on patients and families like Terry and his family.
“We encourage organizations to review their own practice and act on existing guidelines and resulting recommendations to ensure the safest possible care for patients in the future.”