NHS Trust death: Inquest into St Albans woman’s empty oxygen cylinder

An inquest into the death of a woman under the care of West Hertfordshire Teaching Hospitals NHS Trust began on Monday 20 January.

Cecilia Harper (71) died in Watford General Hospital on 9 February 2022, while being transported from her ward to the radiology department. She had been admitted to the hospital five days earlier.

The mother-of-two had reported breathlessness while in hospital, after initially being provided with oxygen via nasal cannula, her oxygen dependency increased and Cecilia was provided with an non-rebreather oxygen mask for the journey and was accompanied by a porter and student nurse. She was conscious when she left the ward, yet by the time she arrived in the ultrasound room she had lost consciousness. A number of medical staff undertook CPR but Cecilia had sadly died.

Upon investigation, it was discovered that Cecilia’s oxygen cylinder was empty, it was not clear when this occurred. During the first day of the inquest, it was heard that research carried out by a doctor at the Trust indicated that 10% of patients transferred to the A&E CT department have insufficient oxygen for a return journey, while 9% of patients made the journey with oxygen cylinders switched off.  

However, a post-mortem report, which identified metastatic breast carcinoma as the cause of death, made no mention of the impact of the empty oxygen cylinder or oxygen dependency.

An inquest took place at the Coroner’s Office for the Area of Hertfordshire to determine the cause of Cecilia’s death. There have been two previous inquest review hearings to ensure all appropriate evidence has been sought, which has delayed proceedings.

The inquest, which was expected to take place over three days, concluded on Tuesday (21 January). The inquest sought to confirm the exact circumstances surrounding Cecilia’s death.

The coroner determined that Mrs Harper died from natural causes, but it is unclear whether there was any problem with oxygen supply, and it is unclear if there was a problem with oxygen supply, if it contributed to her death. 

Read full story

Source: Tees, 21 January 2025