Non-inquest findings into the death of Mr K

Contributing factors

• Inappropriate interhospital transfer to private hospital despite high-risk status
• Lack of consultant-to-consultant handover during transfer
• Failure to identify and document CO2 retainer status on oxygen prescription charts
• Excessive oxygen administration (multiple readings at or close to 100% saturation) in patient with severe COPD
• Prescription and administration of multiple respiratory depressant medications (Diazepam, Oxycodone, Morphine) despite family warning and known risk of respiratory depression
• Inadequate titration of oxygen to target 88-92% saturation range
• Administration of intravenous fluids to patient with aortic stenosis and pulmonary hypertension while normotensive, contributing to fluid overload
• Lack of advanced respiratory management skills in private hospital rehabilitation ward staff
• Private hospital lacked oxygen administration policy and guidelines
• Transfer decision driven by Code Yellow bed capacity issues rather than clinical suitability
• Missing oxygen prescription sticker documentation

Coroner's recommendations

1. Healthcare providers should ensure all patients who are CO2 retainers are clearly identified on all oxygen therapy administration medication orders
2. Oxygen prescription stickers should be made mandatory on all oxygen therapy administration medication orders as a visual cue for clinicians
3. Interhospital transfer procedures should require consultant-to-consultant handover and explicitly document CO2 retention status and high-risk factors
4. Formal procedures should outline referral processes and criteria for patient transfers to private hospitals, particularly during high bed-demand periods
5. Staff training in advanced respiratory management should be provided to rehabilitation unit teams caring for end-stage COPD and CO2-retaining patients
6. Oxygen Therapy Administration procedures should require identification of CO2 retainer patients on all oxygen medication charts
7. Interhospital transfer request forms should explicitly reflect high-risk factors for hypercapnic respiratory failure and management plans for COPD
8. Oxygen prescription policies should specify precautions and target saturation ranges (88-92%) for COPD patients
9. Code Yellow bed management procedures should include safety checks to prevent transfer of high-risk patients unsuitable for step-down care