A 21-year-old girl died because a nurse who was caring for her threw away part of the valve that was meant to be fitted to her breathing apparatus an inquest has heard.
The inquest into the death of Emily Bushaway at Oxford Coroner’s Court on Wednesday heard she suffered respiratory distress, turned blue and died because the hospice staff assembled her ventilator wrongly.
Emily had lived with the rare genetic condition called Niemann-Pick disease type C (NPC) which left her unable to talk and needing a wheelchair to move around.
Her exhausted family had put their terminally ill daughter into respite care at Helen and Douglas House Hospice in Oxford, just to have a few days break.
Emily needed the assistance of a ventilator to breathe after a bout of pneumonia earlier in the year left her lungs damaged.
The inquest heard from Douglas House nurse Katie Philips who changed the flexi-tubing on Emily’s ventilator and accidentally threw a part of the machine’s ‘whisper valve’ away.
She said: “I was going to leave the whisper valve because I thought it was safe to do that, I got the replacement flex and it fitted perfectly.”
The nurse said after she had changed the tube she took Emily into the garden and began to realise something was wrong so she went to speak to her colleague, Emma Morse.
She said: “When she was in the garden I brushed the back of her hair and I noticed her breathing was slightly different every now and again. Then I went to get Emma.”
The nurse admitted she did not have training on how to change the valve on an invasive ventilator, how to troubleshoot it, and what the different alarms on the machine meant.
She accepted before the inquest she had reassembled the ventilator incorrectly as did the nursing home.
Ms Morse, who Ms Philips had asked for help, told the coroner: “Emily was in her chair. I was totally shocked by the appearance as I had not seen her face all morning.
“I fired questions at Katie like ‘how long had she been like this?’
“I had to call an ambulance. I said: ‘I have a patient on a ventilator on her chair and something’s wrong’.
“I became aware part of the valve on the tube was missing. Katie said she had changed it earlier and it had been like for like. The ambulance staff said they needed to know how long she had been without it.”
Detective Sergeant Adrian Thomas told the inquest there had been an investigation to determine if Katie Philips would be charged with manslaughter by gross negligence or if Douglas House would face a corporate manslaughter charge.
However, the Crown Prosecution Service determined there was insufficient evidence to secure a conviction.
Oxfordshire coroner Darren Salter was told another patient at Douglas House had their whisper valve assembled incorrectly until her mother replaced it.
Elizabeth Leigh, director of clinical services’ at Douglas House, said more training had been given to staff since Emily’s death but admitted nurses were not trained to deal with her specific equipment.
“All our patients come in with different types of equipment, that’s one of the complications we’ve had in providing training,” she said.
“We had dealt with patients with tracheostomies and ventilators. We didn’t know about the whisper valve until she arrived.”
Mr Salter delivered a narrative conclusion to the inquest, which said: “The cause of death was respiratory compromise due to the failure of ventilator function utilised for NPC.
“It was discovered that part of the valve on the ventilator circuit was missing which meant Emily Bishaway could not breathe out and was not being ventilated effectively.
“The missing piece involved was unintentionally removed and discarded causing there to be an incomplete circuit and ineffective ventilation.
“Staff were not trained in invasive ventilation and were unfamiliar with the valve and the serious risk of such an occurrence was not adequately highlighted in Emily Bushaway’s care plan, and therefore her accidental death was contributed to by neglect.”
The coroner also said he would write to the Medicines and Healthcare Products Regulatory Agency and Douglas House to see if changes could be made to prevent future deaths.
“One thing I am concerned about is the issue around the whisper valve,” he said.
“It seems to me this is something that was quite easily done if you’re not familiar with the valve.”
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