A&E ventilator that failed still in use one year later
Published 25/08/2014 | 02:30
AN A&E ventilator in a major Dublin hospital, which failed for up to seven minutes as doctors were resuscitating a woman who subsequently died, is still in use.
The ventilator failure will be raised at a resumed inquest today into the death of Diane Martin (34), a mother of three, who died in Tallaght Hospital on May 31 last year, after going into respiratory failure having developed pneumonia.
An earlier hearing was told a ventilator used during her resuscitation at the hospital stopped working without sounding a warning.
The Irish Independent has learned that the ventilator was checked by the hospital and its manufacturer after the event and was returned for use. It was the only ventilator in the overcrowded department at the time but a second machine has since been purchased in recent months following a local analysis of the case.
Ms Martin, from Fettercairn Road, Tallaght, Dublin 24, 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 advanced alcohol liver disease, was on a methadone programme and had been hospitalised four weeks previously after vomiting blood.
Her condition deteriorated within an hour of her arrival and at 9.30am she went into cardiac arrest. She was ventilated and intubated. She went into cardiac arrest for a second time and during attempts to revive her the registrar realised that the ventilator was off.
A written report from emergency consultant Dr James Gray said that the ventilator may have been off for as long as seven minutes during the second resuscitation attempt. It had not been turned off manually nor did it alarm. In his written deposition he expressed concern regarding the ventilator issue. Dr Gray is expected to give evidence in person at today's hearing.
A spokesperson for Tallaght Hospital said it has a rigorous maintenance programme in place for all equipment operating seven days a week. It involves scheduled checks and maintenance while higher frequency checks are carried out on all vital life-saving and life-sustaining equipment.
Asked if the monitoring equipment at Tallaght A&E was satisfactory the spokesperson responded: "The maintenance and monitoring programme also informs decision-making around the upgrading of equipment.
"The ventilator unit referred to was immediately removed from the Emergency Department following the incident. A new ventilator was subsequently purchased for the Emergency Department. A breakdown of critical equipment during use is exceptionally rare."
It is understood that the second ventilator has more functions but two more of these machines are urgently needed in A&E in order to properly monitor the number of critically ill patients in its four resuscitation bays. The A&E unit is currently undergoing an expansion following the damning HIQA statutory inquiry in 2012.