Coroner's Finding: HERCZEG Stephen
Deceased
Stephen Herczeg
Demographics
72y, male
Date of death
2016-09-19
Finding date
2017-08-10
Cause of death
Bilateral pneumothoraces and pneumoperitoneum due to insufflation of the bladder with rupture with contributing infective exacerbation of chronic obstructive pulmonary disease
AI-generated summary
Stephen Herczeg, a 72-year-old patient with COPD and urinary tract infection, died from bilateral pneumothoraces and pneumoperitoneum caused by insufflation of his bladder with oxygen. The oxygen supply tubing was somehow connected to his urinary catheter instead of nasal cannula, causing catastrophic internal gas rupture. Critical clinical failures included: (1) failure to remove nasal cannula when transitioning to room air in ED; (2) inappropriate continuation of oxygen on ward despite clear orders for oxygen saturation target of 85-92% on room air only; (3) inadequate understanding among nursing staff of CO2 narcosis risk in COPD patients receiving supplementary oxygen; (4) failure to monitor that his saturations reached 96% on 2L oxygen (above the 92% upper limit); (5) poor handover communication between staff regarding the oxygen restriction order. The death was entirely preventable had oxygen not been administered on the ward.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Oxygen tubing connected to urinary catheter instead of nasal cannula
- Nasal cannula left insitu despite transition to room air
- Inappropriate continuation of supplementary oxygen on ward
- Failure to monitor oxygen saturations against prescribed limits
- Inadequate handover communication regarding oxygen restriction orders
- Staff lack of understanding of CO2 narcosis in COPD patients
- Inadequate monitoring and observation between 3pm-5pm
- Confusion in EPAS record system leading to interpretation difficulties
- Incomplete admission note marked incomplete due to system lock-out
Coroner's recommendations
- EPAS modifications for CO2 retaining COPD patients should have both upper and lower limits on oxygen saturation levels
- A password should be entered into EPAS when observations are recorded
- The practice of one person taking observations and another person entering data onto EPAS should cease
- If respiratory patients are not admitted to a respiratory ward, the admitting doctor should provide detailed instructions to staff leaving no room for error
- Patients exhibiting confusion should undergo a risk assessment prior to their admission to the ward
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