A coronavirus patient died alone in a hospital side room after his breathing equipment became disconnected and his calls for help were unheard, a report suggests.
Health and safety officials have urged hospitals to ensure that patients in need of a certain type of respiratory support are closely monitored if they are being cared for outside critical or high dependency units.
The Health And Safety Investigation Branch (HSIB) examined the case of a 73-year-old man named only as Terry who was admitted to hospital in December 2020 with COVID-19.
Despite receiving some oxygen, Terry's oxygen levels kept dropping below acceptable levels, so medics decided to use Continuous Positive Airway Pressure (CPAP) - a form of respiratory support that is used when a patient is awake and able to breathe on their own, usually delivered 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 critical care outreach team.
Terry was also seen by a critical care doctor.
On the evening of his second day in hospital, he called for help using his call bell.
HSIB said that the ward was "extremely busy" at this time because of a staff shortage, a new patient arriving on the ward and "competing clinical priorities".
Its report adds: "A nurse was putting on her personal protective equipment ready to enter Terry's room and looked through the observation window.
"She could see Terry lying unmoving on the floor. The CPAP machine and other alarms, which would normally alert staff to a potential problem, could not be heard outside of the side room.
"Terry still had the CPAP mask on his face, but the tubing was disconnected. Terry did not respond to resuscitation attempts and died."
The HSIB investigation highlights challenges faced during the peaks of the crisis, including workforce gaps and challenges delivering treatment outside normal clinical areas.
HSIB said that patients with COVID-19 who are treated with CPAP require close monitoring and observation.
"Caring for such acutely unwell patients in side rooms on general wards poses a safety risk," it added.
It said that there are staffing challenges and other pressures linked to caring for such patients outside critical care or high dependency units.
Staff caring for patients with COVID-19 requiring CPAP on general wards need training and competency assessment to feel confident in delivering care, HSIB added.
It said that hospitals should establish "respiratory support units" where nurses are caring for no more than four patients at a time.
Kathryn Whitehill, principal national investigator at HSIB, said: "The sheer number of patients with COVID-19 needing respiratory support meant the NHS had to adapt and make the best use of their space and resources to meet the demand and minimise the risk of spread of infection.
"This highlighted a safety risk outside of critical care and high dependency areas, and particularly for patients requiring breathing support like CPAP in side rooms on general wards.
"In a side room, monitor alarms cannot be heard and the patient and monitoring equipment they are connected to cannot be seen unless a healthcare professional is present at all times.
"This investigation emphasises the enormous pressure placed on staff and is a reminder of the devastating impact the pandemic had on patients and families like Terry and his family.
"We encourage organisations to examine their own practice, and act on the existing guidance and resultant recommendations to ensure the safest possible care for patients going forward."