Harrogate hospital has “learned lessons” following the death of a woman who became disconnected from her ventilator when she was left alone in a room with the door closed.

Karen Smith was 44 when, in October 2020, she was admitted to the hospital with covid.

She was put on a temporary intensive care ward that had been set up by Harrogate and District NHS Foundation Trust to deal with the high demand of the pandemic.

An inquest heard this week Ms Smith died on the ward after her oxygen mask became disconnected.

The continuous positive airway pressure (CPAP) oxygen machines used on the ward were not connected to the nurses’ station in the way they were on the established ICU.

When Ms Smith’s mask came off and the tube became disconnected around 5am on Saturday, October 24, although the machine’s alarm sounded, there was no way of it sending a signal to the nurses’ station for a rapid response.

The previous day, the hospital’s infection control team had visited the ward and recommended that the doors to each bay, which had been open, should be closed to help reduce the spread of covid.

Dr David Earl, a consultant in anaesthesia and critical care, told the inquest:

“The doors were closed on that Friday and I don’t think enough work was done to recognise the implications of how that might make nursing quite difficult, because you can’t hear behind the doors.

“This is when things start to go a bit wrong, I think, on that Friday.”

On the Saturday evening, a nurse who was covering a meal break had left Miss Smith’s bay to go to the toilet urgently. She had no way of contacting another nurse to cover for her, but believed the original nurse was about to return from her break.

The inquest heard that, during the pandemic, staff were required to remove extensive personal protective equipment (PPE) and go to a bathroom nearby, rather than the one on the ward, which took much longer than usual.

When the nurse she was covering for returned, the disconnection was noticed and Ms Smith’s mask had been completely removed.

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Dr Earl told the inquest many patients find CPAP masks uncomfortable and can attempt to remove them when slightly disorientated, such as when waking up.

The machine’s log indicated Ms Smith had been without hers for around four-and-a-half minutes. A new mask was immediately brought from the store cupboard nearby.

Staff said they hoped the short time of disconnection meant that Ms Smith would not have been affected by the lack of oxygen supply.

The inquest heard that, although her blood oxygen levels quickly rose again, it became apparent to the team on the next shift that she was more sleepy and less responsive than usual.

That night, as her condition further deteriorated, staff called her mother, but she was not allowed to come into the hospital because of covid restrictions.

Addressing Ms Smith’s mother Audrey and brother John, who were at the inquest, Dr Earl said:

“At the time, we were following national guidelines about visiting.

“As someone who worked through all of this, not having visitors all the time was terrible. On intensive care, we spend a lot of time with families getting to know them. To suddenly not have families there was absolutely awful for us, but we know it was even worse for families like yourselves.

“It we could go back, we would get you straight in when we knew [she was dying]. Now, that’s the national guidelines.”

Ms Smith said her daughter had been well enough the day before to be messaging her friends. However, Dr Earl said given the number of days she had been reliant on the CPAP without any sign of improvement, his experience with covid patients suggested she was more likely than not to have succumbed to the virus in the end.

Walkie-talkies introduced

Dr Earl said the hospital had “learned lessons” from Ms Smith’s death and a number of changes had been implemented to prevent the same situation arising again, including changes to nurse rostering and the introduction of walkie-talkies to allow nurses to communicate with each other even when in separate rooms.

He added:

“We realise we can’t make everything perfect, but we try to list all the things where we think there’s a potential danger there and try to minimise them.

“In this new area, we had one of those risk registers and recognised it was constantly evolving, but in these circumstances, it was the best we could do.”

Delivering a narrative conclusion, senior coroner for North Yorkshire Jonathan Heath said Ms Smith, who lived in Wetherby, had died from a hypoxic brain injury caused by becoming disconnected from her oxygen machine. A secondary cause of death was her high body mass index.

Mr Heath said there was no evidence of how Ms Smith’s mask came to be removed and the tube disconnected, so he did not want to make any assumption.

Mr Heath said:

“I am satisfied that a ‘prevention of future deaths’ report is not required.

“Whatever I would be saying to the hospital appears to have been addressed already.”