Prevention of Future Deaths report – Mary Land

Summary

Mary Land was a patient on an Acute Respiratory care unit 'surge' ward at Pinderfield Hospital, being treated for COVID pneumonia against a backdrop of comorbidities.

On 5 February 2021 she was discovered in an unresponsive condition, with the tube connecting her facemask to a BIPAP ventilator detached at the connection point to the mask. In his report, the Coroner raised patient safety concerns relating to how the tubes of her Philips Respironics AF 541 mask became detached from the ventilator.

Content

The Coroner highlighted concerns about how the Philips Respironics AF 541 mask connects by tubing to the BIPAP ventilator by means of a 'push on' connection (rather than a fitting involving positive engagement). Evidence taken at the inquest indicated that this connection has come undone on other occasions as well.

It was noted that the introduction of a filter at the site of the connection increased the potential for the joint to come apart. The Coroner asks whether a more robust docking system could be installed which is less vulnerable to working loose or being inadvertently pulled apart. The report notes that in the case of Mary Land, although the inquest was unable to conclude whether this malfunction contributed to her death, it remains a possibility, and has the potential to contribute to harm in future.

This report was sent to Philips Respironics, the Secretary of State for Health and Social Care and the Mid Yorkshire Hospitals NHS Trust.