Lack of lifesaving ventilators in hospital is a 'disgrace' - consultant tells inquest of mum-of-three
A leading A&E consultant has hit out at the lack of lifesaving ventilators in the emergency department at Tallaght Hospital.
Dr James Gray, emergency medicine consultant, said it is a “disgrace” that engineers at the hospital are forced to “cannibalise” other machines to keep equipment going.
He made the comments at the inquest into the death of Diana Martin (34), a mother of three from Fettercairn Road, Tallaght, Dublin 24 who died at the hospital on May 31 last year after going into septic shock having developed pneumonia.
It emerged during the inquest at Dublin Coroner’s Court that a ventilator used in her resuscitation stopped working without sounding a warning and was off for a seven minute period. Ms Martin was without oxygen for at least four minutes before doctors realised that the machine was off.
Ms Martin, who had a background of alcohol liver disease and was on the methadone programme, was admitted to Tallaght A&E by ambulance at 8.39am on May 31 with difficulty breathing.
She was alert on arrival, however, suffered a cardiac arrest at 9.30am. Spontaneous circulation returned following CPR and she was ventilated at 9.43am.
At 9.55am she suffered another cardiac arrest. As medics attempted to resuscitate her they noticed the ventilator had switched off without sounding the alarm.
The machine was off from 10.02am to 10.09am with staff noticing at 10.06am and commencing manual ventilation using a bag valve mask. She was pronounced dead at 10.15am.
Giving evidence on the second day of the inquest, Dr Gray said that Ms Martin was critical when she came into hospital. The ventilator failure happened “well into resuscitation” during a second round of cardiac arrest.
“Patients who go into a second round of cardiac arrest almost all die and the survival rate is not good,” he said.
The failure of the ventilator was a concern and he raise it with the risk management team, he said. At the time there was only one ventilator machine in the A&E department. A second ventilator machine has since been purchased.
“We need another two. Two is not enough. There is an issue in the hospital around equipment and monitoring. We have monitors that the company has ceased producing parts for since 2011 and suppliers have ceased supplying us parts since 2014,” he said.
The Medical Physics department are doing “Trojan work to keep machines across the hospital going”, he added.
“In fact, cannibalising some machines to keep other machines going. That is a disgrace,” he said.
Head of the Medical Physics department Dr Barry McMahon told the court that the ventilator was sent to the manufacturers who found “no fault with it that could have contributed to it losing power”. Asked by legal counsel for the family if he was saying that the failure was down to someone switching the machine off manually, Dr McMahon said he “cannot speculate as to what happened”. “Technology fails, that is just how life is,” he said.
The ventilator is still in use at the hospital, he told the court.
Pathologist Dr Paul Crotty gave the cause of death as septic shock most likely due to bilateral pneumonia. He told the coroner it is “unlikely” that the ventilator failure was a “critical factor” in the death. Even if the ventilator had been working properly, the probability of death was greater than 95 per cent, he said.
Coroner Dr Brian Farrell said that he had no "causal connection" between the four minutes Ms Martin was without oxygen and her death. He returned a narrative verdict outlining the facts.
Speaking following the inquest, Ms Martin’s brother Wayne Milson said the family still has unanswered questions.
“We are not happy. Can you hold your breath for four minutes? No-one can. She was dependant on that machine. We weren’t told how she died for 15 months until this and now this ventilator issue comes up,” he said, “We want to know was the machine turned off manually, did something turn it off or was there a fault? There is still no answer”.
Tallaght Hospital have released a statement regarding Diana Martin's inquest.
"Tallaght Hospital extends its condolences to the family and relatives of the late Ms. Diana Martin. Tallaght Hospital would also like to state that it has a rigorous maintenance programme in place for all equipment in the Hospital, including the Emergency Department," the statement reads.
"This programme operates seven days a week and encompasses scheduled checks and maintenance by hospital engineers – with higher frequency checks carried out on all vital life saving and life sustaining hospital equipment in high dependency areas.
"The ventilator unit referred to was on a scheduled maintenance program that was fully up to date and a recent manufacturer’s assessment passed the unit for operations.
"In addition, Tallaght Hospital recently purchased another ventilator unit and reviews requirements on an on-going basis."