Father-of-two dies in son's arms after Sandwell Hospital oxygen blunder
A cancer patient died within 20 minutes of returning home after he was deprived of oxygen before leaving Sandwell General Hospital.
Roland Bull, aged 68, was connected to an oxygen cylinder that did not have its safety seal removed and as a result was unable to breathe any of the canister's contents.
The incident happened when the father-of-two was being transferred from a ward to an ambulance on February 11.
Mr Bull, who was in the advanced stages of lung and brain cancer, was going home for palliative care.
But he had been connected to a cylinder that was not dispensing oxygen, Smethwick Coroner's Court heard. He may have been without oxygen for up to 15 minutes.
A member of the team which took Mr Bull home spotted the oxygen canister was still sealed, the inquest was told.
Senior Coroner Zafar Siddique concluded that Mr Bull, of Heronville Road in Hill Top, West Bromwich, died of natural causes contributed by neglect.
Colin Ovington, the chief nurse at Sandwell and West Birmingham Hospitals, said that air coming out of the cylinder did not necessarily mean the seal was open.
He said after Mr Bull's death an investigation was carried out into staff training and the practice of storing oxygen cylinders that were still sealed. A spot check last month found that there were still failures. Mr Siddique said he found that 'absolutely astonishing.'
Mr Siddique said: "During his transfer from the ward when he was taken to the ambulance we have heard evidence that it was five to 15 minutes. The safety seal was still intact and prevented oxygen going through to the patient.
"When he arrived home he went to his bed and oxygen was given to him. Within 20 minutes he had passed away. I conclude this is a death by natural causes contributed by neglect. He was a very poorly man and this did accelerate his death."
Mr Bull's son Carl told the inquest: "My dad was saying to me turn the oxygen up but I said 'I can't' because it was on the setting it was supposed to be on.
"He died there in my arms. He'd been home 20 minutes."
After the hearing, the hospital said it had apologised for the care Mr Bull received.
