Keith Rogers was a 49-year-old hard working father of three when he was admitted to hospital on 2nd August 2021 suffering with worsening shortness of breath. Keith was a determined man who overcame many health problems throughout his life and was working right up until the day before his hospital admission.
During his hospital stay, it was felt that Keith would benefit from a form of non-invasive ventilation known as BIPAP. Historically, BIPAP has only been delivered on respiratory wards and on high dependency units where close supervision of the patient can be achieved. However, due to concerns about BIPAP generating aerosols which may infect others during the covid pandemic, Keith was nursed in a closed side room.
On 4th August 2021, somehow Keith’s breathing machine switched off and the tubing became disconnected. As the default setting of the breathing machine alarm was set to “OFF”, it failed to sound. His cardiac alarm did sound, but could not be heard outside his closed side room. Partner Michelle Meakin is investigating a claim against East Kent Hospitals University NHS Foundation Trust and represented the family at the recent Inquest.
We heard evidence at this Inquest which indicated that insufficient safeguards were in place to ensure patient safety for patients such as Keith, who were nursed in side rooms on BIPAP. Keith was a particularly vulnerable patient as he was in a severely compromised state and had reduced power in all 4 limbs. In particular, he did not have sufficient use of his arms but managed on a day-to-day basis around the home with several adaptations.
Despite this, we heard evidence to the effect that:
Keith was expected by both clinical staff and his family to survive this hospital admission. However, tragically, Keith died on 4th August 2021. The Coroner came to the conclusion that had his breathing machine not failed, he would have survived.
Michelle Meakin comments:
“This is not the first case my department has dealt with involving death due to a machine alarm failure under the care of this hospital Trust. I was concerned to note that the Trust still doesn’t have a protocol in place should patients on non-invasive ventilation have to be nursed in closed side rooms again. This was obviously a concern shared by the Coroner. I sincerely hope the Trust has learned lessons from this case to ensure no other families have to suffer in the same way that Keith’s family have.”