Connor Turner
6 Mar 2015 · Coroner David Hinchliff · West Yorkshire (East)
The coroner's concerns
1. inadequate training of parents and carers in oxygen supply transfer
“There is no system in place for nursing staff to instruct and train parents and carers in the transfer of the oxygen supply from the main supply to a portable oxygen cylinder”
2. lack of supervision during initial oxygen transfer tasks
“That parents and carers should be initially supervised in performing this task until they are deemed to be competent to do so”
3. patient discharge without verified oxygen apparatus functionality and user competence
“when a transfer has been made in preparation for the patient leaving the hospital, albeit temporarily, the patient should not be allowed to leave until an independent check has been made and all concerned are satisfied that the apparatus is functioning correctly and that those taking the patient out of hospital are competent to use the apparatus and that the appropriate reference to this should be made in the case notes”