The family of a pensioner have called for extra staff training after it was revealed he became the second patient in a year to die at a Sheffield Hospital after not being provided with oxygen during a ward transfer.
Ronald Burns, 84, of Intake, was admitted to A&E at Sheffield’s Northern General Hospital with breathing difficulties and signs of a chest infection on March 14 last year.
Following initial treatment, his condition improved and arrangements were made for him to be moved to the coronary care unit.
However, an inquest into his death held at Sheffield’s Medico-Legal Centre was told that upon arrival at the unit his condition had deteriorated significantly.
A subsequent investigation revealed that a portable oxygen cylinder had not been turned on during the transfer.
Ronald, a former self-employed builder, died four days later on March 18.
Following his death, Ronald’s family instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the care he received by Sheffield Teaching Hospitals NHS Foundation Trust, when he was a patient at Northern General Hospital.
Investigations have revealed that six people, including two at Northern General, died in three years after staff had accidentally not administered oxygen to patients during transfers.
Around 400 similar incidents where patients had not died were recorded across the country in the same period.
Following the death of a patient, who did not receive oxygen during a ward transfer at Northern General in March 2016, a coroner issued a Preventing Future Deaths Report raising concerns that she believed future deaths could occur in similar circumstances unless action was taken.
Ronald’s family, including wife Connie, aged 88, and their children, Craig and Dawn, aged 54 and 58, have now urged Hospital Trusts across the country to learn lessons from his case.
It comes after a coroner recorded a conclusion that the failure to provide oxygen during the transfer contributed to Ronald’s death.
Tania Harrison, the specialist medical negligence lawyer at Irwin Mitchell’s Sheffield office who represented the family at the inquest, said after the hearing: “Ronald was a devoted, husband, dad, granddad and great-grandfather and all his family are still devastated by his death.
“The past months have been incredibly difficult for Ronald’s family, but we are thankful to the coroner for providing the family with the vital answers they needed with regards to Ronald’s death.
“During the course of our investigations it was established that it was the second time in just over 12 months a patient had died at Northern General Hospital after a portable oxygen tank was not switched on during the ward transfer of a patient.
“This combined with the fact there has been more than 400 other incidents across the country over three years is incredibly worrying. We believe this highlights a lack of training among staff.
“Therefore it is vital hospital trusts take swift action to put appropriate measures in place to ensure that a repeat of these incidents does not happen again.
“Ronald’s death and the inquest findings are an important reminder that the NHS must always put patient safety first.”
After the hearing Craig said: “Our family is angry and upset by the way the hospital treated Dad, particularly as we were not told about the incident with the oxygen until several days after his death. To then find out that something similar had previously happened was unbelievable.
“The inquest has been a very difficult time for us and it has been hard to once again hear of the issues that Dad faced in his care.
“Problems like this are unacceptable and while nothing will ever change what has happened, we are glad that the failings have been highlighted by the Coroner and steps are being taken to ensure issues of this nature are never allowed to happen again.
“You place great faith and trust in the NHS to provide a quality standard of care, so it is desperately sad to think that Dad did not get that.”
Dawn added: “I am deeply saddened and upset not only about what has happened to Dad but also the manner in which the hospital have responded.
“It is difficult not to feel that someone has taken what little time we had left with him away from us all. Dad paid the ultimate price for a careless mistake.
“The fact that the hospital chose to conceal this from us throughout upsets me even more. To find out about the potential hospital error from the Coroner’s office was a huge shock for our family. It simply should not have happened that way.”
Dr David Throssell, Medical Director, Sheffield Teaching Hospitals NHS Foundation Trust, said: "We always strive to provide the best possible care to all our patients and so it is deeply regrettable that a genuine human error was made regarding the additional oxygen supply for Mr Burns during his short transfer from the A&E department to a ward area.
“This is a very uncommon incident in our hospitals but we do acknowledge that a similar incident occurred a few weeks before.
“We are sorry Mr Burns’ family were not aware of this but I would like to reassure them and our patients that we have taken the incidents very seriously and already improved staff training, documentation and processes regarding oxygen use during the transfer of a patient.
“I would like to reiterate once again how sorry we are that this happened although I appreciate that no words can make up for the devastating loss of Mr Burns for his family and friends."