Coroner's finding on elderly woman's death: Oxygen tank was not turned on

Coroner's finding on elderly woman's death: Oxygen tank was not turned on

Coroner's inquiry into death of 83-year-old woman during hospital transfer

Jul 31, 2014 6:00am

1: At 6.40pm, a three-person Mount E Novena transfer team prepares to transfer Madam Ramasamy Krishnama from TTSH to Mount E. The nurses prepare a portable ventilator and oxygen tank. They put the elderly patient on a gurney and place her on the paraPAC portable ventilator. The team hears a hissing sound, which they take to mean that the oxygen supply to the ventilator is switched on.TNP

INFOGRAPHICS: CELESTINO GULAPA

By: RONALD LOH
It was a basic task - ensuring their patients had oxygen to breathe while she was being transferred from one hospital to another.

But when the medical team heard a hissing sound, they mistook it to mean that the ventilator was already switched on.

That mistake lead to the death of Madam Ramasamy Krishnama, 83, who suffered hypoxic brain injury, which occurs when insufficient oxygen gets to the brain, in July last year.

Yesterday, State Coroner Marvin Bay questioned whether there were sufficient safeguard procedures in place during the transfer, where the roles of the medical team are critical.

He also called for a review of protocols when transferring a patient from one hospital to another.

Madam Krishnama's son told The New Paper yesterday that his mother's death had been a shock to all of them.

"All we wanted was for her to come back (from the hospital) safe and sound," he added.

Parkway Shenton, which was handling the transfer and is part of the healthcare chain with Mount Elizabeth Novena Hospital and Gleneagles Hospital, said it is "deeply sorry for the family's loss" and is taking a very serious view of the incident and has since reviewed and revised its protocols that address the relevant issues.

Read the full report in our print edition on Thursday (July 31). Subscribe to The New Paper, now available in print and digital, at http://bit.ly/tnpeshop.

- See more at: http://www.tnp.sg/news/coroners-finding-elderly-womans-death-oxygen-tank-was-not-turned#sthash.zVkE6LS8.dpuf


- wong chee tat :)