The German valve manufacturer VTI has since reported nine cases of ignition and was due to examine a further 20 regulators, although no defects had been reported up to January this year. Following the inquest a jury returned a verdict that the 67-year-old’s death was accidental and the “most likely cause” was due to the build up of pressure caused by particles in the tank’s cylinder.
Paramedics were in the process of giving Mrs Hadley oxygen treatment at her home, in New Street, Shelfield, when sparks came from the tank setting alight the armchair she was in.
The flames spread and engulfed the house.
The jury heard that the incorrect sequence had been used by a paramedic to open the cylinder which increased the chance of ignition occurring.
Following the inquest, West Midlands Ambulance Service University NHS Foundation Trust apologised to Mrs Hadley’s family.
In his prevention of future deaths report sent to the Health & Safety Executive (HSE) and the Care Quality Commission (CQC), senior coroner Mr Zafar Siddique stated: “In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
“All agencies involved may wish to consider reviewing and issuing guidance for the operation and use of oxygen cylinders. I am particularly concerned about the use of oxygen cylinders in the community in general and would invite the HSE and CQC to consider issuing further guidance urgently.”
The retired shop worker had been suffering with a high temperature, a suspected symptom of coronavirus, when her concerned family members phoned 999 for help, shortly before 5pm on Easter Monday last year.
The ambulance crew found that her oxygen levels were low and combined with breathing difficulties, they decided to give her oxygen, but the paramedic was not trained in accordance with manufacturer’s instructions for the sequence of opening the tank.
As a result a rare phenomenon known as “adiabatic compression” resulted, caused by a rush of oxygen when a valve is opened quickly.
The crew were unhurt.
A statement from West Midlands Ambulance Service University NHS Foundation Trust said: “This was an extremely rare event. As a trust, we immediately investigated what had happened and rapidly put measures in place to stop such an incident happening again.
“We have also worked with a number of other agencies to ensure this learning is understood and acted upon on a national level,” the trust’s consultant paramedic Rob Cole stated.
A copy of the report has also been sent to the Medicines and Healthcare products Regulatory Agency.