A MOTHER died after being given huge amounts of oxygen by a nurse “not trained” in the procedure.
Bosses at Sunderland Royal Hospital have apologised for the death of pensioner Elizabeth Waldron, and said the tragedy has led to new systems being put in place.
Mrs Waldron died less than two hours after being administered uncontrolled levels of oxygen when she fell seriously ill on Ward E51.
But an inquest into the 77-year-old’s death was told she may not have died had correct procedures been in place for nursing staff when delivering oxygen therapy.
Staff nurse Rani George, who gave Mrs Waldron the oxygen, told Sunderland Coroner’s Court: “I had not had any proper training before this incident with regards to the administration of oxygen to chronic obstructive pulmonary disease patients.
“I did not know that I could not use a high flow of oxygen.”
Hospital bosses said lessons had been learnt from Mrs Waldron’s death and medics, including staff nurse George, had received extra training.
City Coroner Derek Winter said he intends to write to the Secretary of State for Health, advising that all hospital trusts should be aware of guidelines to prevent a recurrence of the tragedy.
Mrs Waldron was admitted to hospital on July 20 last year, suffering from severe breathing problems due to Chronic Obstructive Pulmonary Disease (COPD). Her condition deteriorated during the following 24 hours.
By 5am on the morning of July 21, Staff nurse George noticed the pensioner’s oxygen saturation levels had fallen to critical levels of just 41 per cent.
Up until that point doctors had instructed levels be maintained between 88 and 92 per cent.
The staff nurse increased the oxygen supply in a bid to stabilise Mrs Waldron’s condition, but levels then reached up to 97 per cent.
A doctor was contacted at 5.05am to assess Mrs Waldron.
However, the inquest heard staff nurse George failed to pass on information about the critical oxygen level changes and the assessment was not carried out until around 5.30am.
Mrs Waldron was pronounced dead at 6.30am.
Coroner Mr Winter said: “Had the doctor been made aware of the oxygen saturation levels, it’s more likely than not they would have seen it as a more urgent requirement.”
Judith Hunter, head of nursing and patient safety at Sunderland Royal, said the “tragic” death of Mrs Waldron had led to a review of communication between nurses and doctors, and the creation of an “oxygen group” to develop best practice.
She added: “It is the role of the nurse to make sure his or her medical colleagues are provided with the necessary information they need when taking over the care of a patient.”
“Mrs Waldron’s tragic death has given us the impetus to support patients better in the future.”
Mr Winter recorded a narrative verdict stating Mrs Waldron, of Peterlee, died of natural causes contributed by oxygen levels not appropriately maintained and managed, and the absence of a more timely medical review.
After the inquest, her loved ones released a statement.
They said: “The family are pleased that the inquest is now over and would like to thank the coroner Derek Winter for his thorough inquiries.”