Police probe after Rotherham Hospital death

DETECTIVES launched an investigation when a hospital patient died after his breathing machine became disconnected, an inquest heard.

Police, the Medicines and Healthcare products Regulatory Agency and the machine manufacturers set up inquiries after the death of ex-miner Dennis Payling.

The 79-year-old single man of Cromer Close, Rawmarsh, was taken into Rotherham General Hospital after suffering a stroke and put on a Continuous Positive Airway Pressure machine to help his breathing through a mask.

But the machine was accidentally disturbed as a nurse and health care assistant gave the pensioner a bed bath and the CPAP became disconnected for up to 20 minutes.

Nurse Saria Ramful, who admitted she was unfamiliar with the machine, noticed a white disc-shaped object fall from the machine to the floor and afterwards the patient’s oxygen saturation levels (SATS) in his blood began to fall.

Staff nurse Heather Bell, who took over from the pair, said she could hear “a commotion” and talking and they seemed “stressed.”

Mr Payling’s SATS plummeted to 69 per cent when they had earlier been at normal levels of 94 per cent and an alarm was sounding on the patient’s monitor screen.

She knew something was wrong and looked at the patient. “I thought he was very ill and thought he was going to die,” she said.

She discovered the CPAP machine had been “knocked” while the patient was being bed-bathed.

Nurse Bell admitted she did not “have a clue” what to do with the machine so rang the on-call physio Katherine Bailey, whose department sets up the devices.

She described the set-up of the CPAP over the phone and Ms Bailey appeared happy and as the patient's SATS levels rose again no doctor was called.

But Mr Payling rapidly deteriorated and when a doctor was called he said there was nothing more that could be done for him and he died shortly afterwards.

Ms Bailey said the nurse told her the disc and a green T-piece had become disconnected from the machine when the patient was moved.

The T-piece had to be in place for the machine to work properly and dispense oxygen while the disc was just a filter. After receiving her advice Nurse Bell reconnected the machine.

Mr Payling was admitted to the Rotherham hospital on February 16 last year and put on the CPAP machine three days later.

After he died on February 21 the police investigation discovered a blow-off valve had been put into the breathing circuit the wrong way round and “an unknown quantity” of oxygen provided to the patient.

Dr Patricia Bain for the hospital trust who carried out its own inquiry said: “There was a period of 15 to 20 minutes where there is some debate as to whether the machine is connected.

"Our understanding is that the machine was providing oxygen throughout the whole of that period.”

She said the hospital had reviewed its procedures and was giving extra training on the management of CPAP machines which would in future be housed in a special respiratory unit.

The Rotherham Coroner Nicola Mundy adjourned the hearing after being told police reports indicated the machine may have been reconnected earlier than was thought.