Sunday 25 February 2018

Inquest into mum's death told ventilator failed during CPR

Diana Martin
Diana Martin

Gareth Naughton and Brian Byrne

THE son of a young mother who died in hospital after her ventilator stopped working has told how he has been forced to raise his younger brother since her death.

A ventilator at Tallaght Hospital failed for up to seven minutes as doctors were resuscitating a woman who subsequently died, an inquest at the Dublin Coroner's Court heard yesterday.

Single mother-of-three Diana Martin (34), 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 inquest into her death, it emerged that a ventilator used during her resuscitation at the hospital stopped working without sounding a warning.

Diana's eldest son Dean, who celebrated his 20th birthday this week, said her death had spilt the family apart.

He said he has been living with his 16-year-old brother Jamie since his mother died, while his sister Cadie (9) lives with her aunt.

Dean told the Irish Independent: "The family hasn't been the same since she died. Unfortunately, I have to get on with it. I've to deal with the consequences. I've been raising my brother for the past year."

Ms Martin arrived at Tallaght A&E at 8.39am on May 31, 2013, 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 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.

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.

Irish Independent

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