A retired headteacher who was receiving treatment for coronavirus died after an oxygen tube became disconnected from his mask, an inquest has heard. James Johnson, 83, from Wrexham, was admitted to Wrexham Maelor Hospital on January 3, 2021.
Sadly, Mr Johnson, who was being treated for Covid pneumonia, died 10 days later at the hospital's Bonney Ward, where continuous positive airway pressure (CPAP) respiratory support was administered over the course of the pandemic. In the days leading up to his death, Mr Johnson's condition deteriorated and, by January 12, a move to palliative care was under consideration.
At the time of Mr Johnson's death, the pandemic was in its third wave, which was the most difficult period for hospitals in north Wales, according to Michelle Hughes. Ms Hughes, an interim surgical matron who was called to assist at the hospital due to it being in an "extreme crisis" situation in January 2021, appeared as a witness at the inquest in Ruthin County Hall on Wednesday via video link.
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The inquest heard that Mr Johnson was receiving CPAP treatment along with three others in bay four on Bonney Ward. There were four other CPAP patients on the ward across two other bays at the time. Due to the pressures of the pandemic, only two members of staff had been fit tested to be able to access the bays.
Catherine Norgrove was one of the two ward staff allowed into the bays and was on the early shift on January 13. Mrs Norgrove told the court that the best working practice is for one nurse to care for two patients on this ward, but on this day she and a health care support worker had to care for a total of eight patients - a situation she described as "very distressing" as she "couldn't get to every patient".
When not inside the bays themselves, Mrs Norgrove said it was possible to check the monitors of every patient inside them through a large window. The monitors had been turned towards the window so that the saturation levels for each patients could be viewed from the hallway outside. However, the window did not offer a complete view of the tubes that ran from the CPAP machines to the masks worn by the patients.
In order to enter the bay, Mrs Norgrove would have to put on fresh PPE each time, and this process took around 30 minutes to complete, the inquest heard. The nurse entered bay four to check on Mr Jones at around 10.30am, at which time Mr Jones' oxygen levels were not a significant concern with the tubes from his mask to the CPAP machine fully connected.
At around noon, Mrs Norgrove had donned fresh PPE and had gone to bay three to help the patients with lunch - feeding them and checking their figures. The health care support worker who was working the ward with her that day was in bay four with Mr Johnson doing the same at this time.
Mrs Norgrove then left bay three at around 1.30pm. She told the court that she took off her PPE and prepared the medication round for bay four upon leaving bay three. At this point, she saw that Mr Jones' saturation levels had dropped and a doctor was called to attend to Mr Johnson.
The doctor saw that the oxygen tube that fed into Mr Johnson's CPAP mask was not connected and he was pronounced dead at 2.10pm. A post mortem was conducted by Dr Muhammad Aslam who provided a cause of death of Covid pneumonia with heart disease as a contributory factor.
An investigation conducted by Betsi Cadwaladr University Health Board could find no other instances in which an oxygen tube from a CPAP machine had become disconnected from a mask. The machine was examined as part of the investigation and was found to have no issues. Using tape and glue to attach the oxygen tube to the mask had been considered in previous risk assessments but this was found to be ineffective with the current set up the least risky method, the inquest heard.
The chair of the investigation told the court that the tubing does not disconnect from the mask easily and that removing it would require between 3kg and 8kg of pressure. As such, the investigation found it unlikely that Mr Johnson deliberately removed the tube due to his condition at the time. The most likely cause, the investigation found, was that Mr Johnson leaned on the tube while being repositioned and that this led to the tube becoming disconnected from the mask.
As part of the learnings made from the investigation into Mr Johnson's death, a "tag in, tag out" system has been implemented in order to ensure that a member of staff is always present in the bays in Bonney Ward. Auditing has taken place at Wrexham Maelor to ensure that the learning is followed through with some general themes from the investigation set to be applied across the health board.
John Gittins, senior coroner for north Wales east and central, recorded the following narrative conclusion: "On the 3rd of January 2021, the deceased was admitted to Wrexham Maelor Hospital where he was being treated for Covid pneumonia. By the 10th of January his declining condition required him to receive treatment which included continuous positive airway pressure respiratory support and due to the pressures on the hospital arising from the Covid pandemic, this was being delivered via a machine which normally would have been utilised for home care.
"On the 13th of January 2021 staffing pressures meant that only two members of staff had been fit tested allowing them access to the room where Mr Johnson was being cared for and together they had to care for a total of eight patients, whereas optimum care in a non-pandemic scenario for CPAP patients would have been one nurse to to two patients.
"At around 1.30pm on that date it was noted that Mr Johnson's saturations had dropped and the attending doctor verified him deceased at 2.10pm, whereupon it was noted that the oxygen tube which fed into the CPAP mask was no longer connected. It is not possible to establish how the oxygen tube had become disengaged, however the reduction in the delivery of oxygen to Mr Johnson would have led to increasing hypoxia and it is probable that this would have hastened his death."
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