Covid patient died in hospital side room after calls for help unheard

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A pensioner died alone in a room next to the hospital after his respiratory tract severed and his appeal for help went unanswered.

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The Healthcare Safety Investigation Branch (HSIB) said that a 73-year-old man, identified only as Terry, was hospitalized with coronavirus in December 2020.

The married father of six children was given oxygen but the gas level in his blood repeatedly dropped below the correct level, so doctors attached a breathing machine called a CPAP. The device produces positive pressure through a tube and mask, but is non-invasive.


He was kept in a side room away from a ward because the CPAP procedure can pump respiratory particles into the air, meaning Terry had to be isolated from other patients to prevent the spread of COVID-19. He was regularly visited by nurses.

However, around 8 p.m. on his second day in the hospital, Terry used his call bell to ask for help. In its report, the HSIB said: “The ward was extremely busy at this time because of staffing constraints, as well as competing clinical priorities and the expectation of a new patient coming to the ward.

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“A nurse prepared to enter Terry’s room putting on her personal protective equipment and looked through the observation window. She could see Terry lying on the floor under the bed with his head down.

“CPAP machines and other alarms, which usually alert employees to a potential problem, cannot be heard outside the side room.”

Terry’s breathing tube was cut, although his mask was still on. He could not be revived.

During the investigation, it was found that at that time the nurses of TERI’s ward were treating 10-10 patients.

The HSIB said: “The huge number of patients with Covid-19 needing respiratory support meant that the NHS had to make the best use of its space and resources to meet demand and reduce the risk of the spread of infection “

It has now ruled that keeping CPAP patients in the side room is dangerous, and has reintroduced advice for hospitals based on guidance from the Intensive Care Society, the British Thoracic Society and others.

Investigators said staff caring for COVID-19 patients need CPAP in general wards, who need training and competency assessment to feel confident in delivering care, and hospitals need “respiratory support units”. Where nurses are not treating more than four patients at a time.

According to the report, bosses should review their policies regarding providing such treatment and whether they have the ability to properly monitor alarms.

HSIB did not name the hospital in TERI’s case.


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