Popular yachtsman's death hastened by hospital's 'gross failure' after oxygen blunder
Health officials have overhauled their procedures after a vulnerable patient being taken to the toilet was left without oxygen. A hospital worker took Joe Abrahams, who had a lung condition, to relieve himself - along with his oxygen cylinder - but failed to ensure it was correctly open.
When the worker returned to collect Mr Abrahams, 74, it became clear he had not had the oxygen for the intervening 10 minutes in the incident at Ysbyty Gwynedd in Bangor, an inquest heard. He died the following day on April 17 last year.
Kate Robertson, senior coroner for north west Wales, found at an inquest that the popular yachtsman's death had been due to a "gross failure" and was "hastened by neglect". Now Betsi Cadwaladr University Health Board says it has made sweeping improvements to its protocols in such circumstances. You can sign up for all the latest court stories here
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The inquest heard Mr Abrahams, of Pwllheli, had a number of health conditions including ischaemic heart disease, lung cancer and diabetes. He was admitted to Ysbyty Gwynedd on March 28 last year.
On April 16 Mr Abrahams asked for help to go to the toilet at about 11pm, the coroner ruled. He was on a cylinder to help him breathe attached to a nasal cannula - a tube through the nose.
A health care assistant took him with the cylinder to the toilet and transferred him to a seat. Ten minutes later she returned to check on him.
There was a "noticeable change in colour" and Mr Abrahams looked "sweaty" and said he felt dizzy. His oxygen level was low and she summoned help.
'Gross failure'
At 2.30am or 3am the following morning the hospital contacted Mr Abrahams' daughter to say he was "unlikely to survive". He died later that day.
The coroner found: "It appears that the oxygen cylinder had not had oxygen being released because the seal cap on the side of the cylinder was still on the cylinder. Mr Abrahams was without the required oxygen."
The coroner noted that there had been proposed treatment for Mr Abrahams' cancer. She said: "But for this (cylinder) incident Mr Abrahams would not have passed away at the time. His death was hastened by the lack of oxygen for that ten-minute period."
The coroner said Mr Abrahams died from respiratory failure due to carcinomatosis, and also a lung condition, ischaemic heart disease and hypoxia due to non-delivery of oxygen.
His death was hastened by the non-delivery of oxygen and it was a "gross failure", she concluded. "The side valve ought to have been opened. On that basis there was a training gap for the student nurse working as a health care support worker.
"I do find that this amounted to a gross failure to provide basic medical attention. Death was due to natural causes contributed to by neglect." The senior coroner said she would write to the Health Minister and BCUHB about the case.
Mr Abrahams, whose full name was Jonathan Keith Anderson Abrahams, was originally from Stratford-upon-Avon. He moved to Abersoch then Pwllheli and had been a sailmaker and yachtsman.
'Profoundly sorry'
After the inquest his family said they hope lessons have been learned by the hospital. Daughter Carrie Abrahams said "We are pleased with what the coroner said and we just want to make sure people learn by their mistakes."
In a statement Angela Wood, Executive Director of Nursing at Betsi Cadwaladr University Health Board, apologised and said enhanced safety measures have been put into place. She said: “On behalf of the Health Board we are profoundly sorry and offer our deepest sympathies to Mr Abrahams family for their loss.
“We fully accept the Coroner’s findings and would like to apologise that the care Mr Abrahams received fell below the standards we would expect. We have implemented a number of enhanced safety measures as a result in order to reduce the likelihood of this failure being repeated.
“The Health Board has taken a number of actions since Mr Abrahams death which includes safety alerts, training sessions, inclusion of cylinder preparation in mandatory life support training, updated guidance, patient transfer checklists and oxygen competencies.
“To enhance our safety measures further the Health Board has introduced a directive that specifies that patients requiring the administration of oxygen for transfer to the bathroom or to another ward/department, must have the cylinder checked and set up by a Registered Healthcare Professional and be accompanied at all times.”
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