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Sunday 31 August 2014

Hospital ventilator failed for seven minutes as doctors tried to resuscitate woman - inquest

Gareth Naughton

Published 08/07/2014 | 15:25

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Diana Martin - see Garth Naughton inquest copy re ventilator failing in Tallaght Hospital
Diana Martin
Tallaght hospital
Tallaght hospital

A ventilator at Tallaght Hospital failed for up to seven minutes as doctors were resuscitating a woman who subsequently died, an inquest heard.

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Diana Martin (34), a mother of three from Fettercairn Road, Tallaght, Dublin 24, died at the hospital on May 31 last year, after going into respiratory failure having developed pneumonia.

At the Dublin Coroner’s Court inquest into her death, it emerged that a ventilator used during her resuscitation at the hospital stopped working without sounding a warning.

Ms Martin arrived at Tallaght A&E at 8.39am after calling an ambulance because she was having difficulty breathing. The family told the coroner that she walked to the ambulance unaided.

Initially, Ms Martin was alert and able to give staff a medical history when she was seen in the resuscitation room. The court heard she had a background of alcohol liver disease and had been hospitalised four weeks previously after vomiting blood. She had been feeling unwell for two days prior to her final admission with difficulty breathing, a chesty cough and jaundice.

Her condition deteriorated within an hour of her arrival and at 9.30am she went into cardiac arrest. She was ventilated and intubated and spontaneous circulation returned following CPR. She subsequently went into cardiac arrest for a second time at 9.55am and CPR was again administered. It was during the latter part of this attempt to revive her that the registrar realised that the ventilator was off. A bag valve mask was used until the ventilator was started again. CPR was continued, however, Ms Martin was pronounced dead at 10.15am.

Tallaght Hospital was not represented in court. A report from Dr James Gray, consultant in emergency medicine at the hospital, read into the record by coroner Dr Brian Farrell, said that the ventilator may have been off for as long as seven minutes during the second resuscitation attempt. Dr Gray's report also said that it had not been turned off manually and no alarms went off which staff would have expected if there was an issue. He said that he was subsequently informed that that the machine "previously went off without warning" in the A&E department.

The coroner said that pathologist Dr Paul Crotty gave the cause of death as septic shock due to bronchopneumonia on a background of cirrhosis of the liver and liver failure. Ms Martin was on the methadone programme and a high level of the drug was found in her system. Dr Crotty was aware of the ventilator issue when he carried out the post-mortem, said Dr Farrell, and in his report states that he thinks it “unlikely” that it was a critical contributory factor to death.

Dr Farrell said that he while he was not saying that Dr Crotty was incorrect, he was not satisfied about the ventilator issue. He adjourned the inquest to August 25 to hear evidence from the hospital.

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