Patient dies after staff forgot to turn on oxygen tank

Madam Ramasamy Krishnama was warded in June last year at Tan Tock Seng Hospital (TTSH) following a heart attack she had had. About a month later, she was being transferred to Mount Elizabeth hospital when the staff accompanying her forgot to turn on the oxygen tank after putting her on a ventilator.
According to news reports of a coroner’s inquiry, Mdm Ramasamy “became unresponsive in the three to four minutes that passed before the oxygen was turned on.”
Her poor health and her critical condition at the time, plus the deprivation of oxygen to her brain “probably precipitated” her death, a coroner’s inquiry found.
Mdm Ramasamy, who was 83-years old, “had been alert and comfortable before being handed over to the receiving team” during the transfer, a police investigation report submitted to the court said. It added that her vital signs had been “stable” in the hours before the incident which led to her death.
According to the Straits Times, “[Shortly] after being transferred from her bed to a trolley and put on a portable ventilator on July 8 last year, Madam Ramasamy’s level of oxygen saturation was noted to be ‘unrecordable’, raising concerns that it was very low.”
The transfer team then checked their equipment to find out the cause.
“One of the nurses realised that a switch on the portable oxygen tank used to supply the portable ventilator had not been turned on,” the Straits Times reported.
Staff then turned on the oxygen supply with the ventilator turned up to “maximum setting”, to no avail, despite cardiopulmonary resuscitation being performed on her as well.
Mdm Ramsamy was pronounced dead shortly after.
A medical report submitted with the police report said Mdm Ramsamy’s heart “was the major problem.”
The report said that given her “poor health” and the lack of oxygen, together with her history of diabetes, high blood pressure and “excessive levels of fatty substances in the blood’, Mdm Ramsamy “would have expired in the very near future even with the best treatment.”
An internal review by Parkway Shenton, which is the parent company of Gleneagles Hospital which provided the transfer team, found that the team “had assumed that the switch was already turned on as staff had heard air gushing out when the ventilator was connected to the oxygen tank.”
They thus proceeded to check the other equipment, without knowing that the cause was the switch not being turned on.
Madam Ramasamy has six children and more than 10 grandchildren.
The coroner’s findings will be issued on 30 July.
The incident is the latest this year which involved negligence and deaths of patients.
In May, a pharmacist was fined S$6,000 for causing the death of a 78-year old women in 2010 by prescribing the woman ten times the amount of a diabetic drug she was to administer.
The woman developed brain damage as a result of the overdose and died.

In June, two doctors were fined S$26,000 and S$8,000 for the death of their patient on whom they had performed a liposuction operation.
They were found guilty of “not complying with the terms and conditions stipulated for conducting the procedure” in the 2009 death of their patient.

In 2011, Ms Lian Huizuan collapsed in Changi Women’s Prison and died shortly after.
A coroner’s inquiry found that she had been prescribed an excessive amount of medication.
She was found to have19 times the therapeutic range of the drug, amitriptyline, in her blood on the day she died.
Ms Lian’s father has taken legal action against the doctors from Raffles Medical Group (RMG) who were the service providers engaged by the Singapore Prisons Service then.

In 2013, the Singapore Prison Service announced that Parkway Shenton, which provided the transfer team to transfer Mdm Ramsamy from TTSH to Mount Elizabeth, had taken over from RMG as its “medical service provider”.