The reference event

An 83-year-old man was admitted to hospital via the Emergency Department. He complained of feeling unwell for the previous few weeks, decreased appetite, vomiting after eating, loose stools and abdominal discomfort. A medical history of type 2 diabetes, rheumatoid arthritis, hypertension (high blood pressure) and high cholesterol were recorded.

The following day the patient was transferred to the Acute Medical Unit with a diagnosis of
hyperglycaemia (high blood sugar) and acute kidney injury; he was later transferred to a diabetes and endocrinology ward.

Eleven days after being admitted, the patient had recovered enough for a discharge plan to be made to allow him to return home. However, on day 12 his clinical condition unexpectedly began to deteriorate,
and this progressed to the extent that over the course of a few hours he became unresponsive.

A nurse began cardiopulmonary resuscitation (CPR) and a resuscitation trolley was brought to the bedside by a care support worker. The resuscitation team arrived, and the patient’s breathing was supported using a bag-valve-mask, with a reservoir bag attached, connected to a portable oxygen supply with a standard valve.

After approximately 10 minutes of CPR, it was recognised that the reservoir bag was not inflating between breaths, which was interpreted by the resuscitation team as an indication that the patient was not receiving supplementary oxygen. The resuscitation team concluded that the oxygen cylinder was empty, so the cylinder was replaced, and the oxygen supply checked as being delivered to the patient. Despite further CPR, the patient remained unresponsive and CPR was eventually stopped. The patient subsequently died.

The following morning the medical gases porter arrived on the ward to replace the cylinder that was thought to be empty. Upon examination, the cylinder was found to be full.

HSIB then carried out a wider investigation and here are their findings.