Cancer patient died struggling for breath as Basingstoke hospital staff panicked (From Basingstoke Gazette)
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Cancer patient died struggling for breath as Basingstoke hospital staff panicked
A CANCER sufferer died “struggling to take a breath” as hospital staff panicked around him, an inquest heard.
The hearing at Alton Magistrates’ Court was told how Basingstoke hospital has overhauled its procedures following a catalogue of errors made while medics tried and failed to treat terminally-ill David Chipchase.
The 71-year-old grandfather, from Overton, who had terminal cancer of the lungs and trachea, struggled for breath as equipment failed and medics, not trained to deal with the situation, were “in a state of panic”.
He died before correct suctioning equipment could be used. The inquest heard that the equipment would not have saved his life.
The inquest heard the only nurse on E3 ward with the correct training to deal with patients with tracheostomies had called in sick earlier in the day on April 4.
Mr Chipchase, who worked for much of his life as a biochemist at Basingstoke hospital, was self-caring and would clear his own airways using a portable suction unit (PSU).
He was using a PSU in his hospital bed in the evening of April 4 when he gestured for nurse Claire Mason to help him.
She tried to use the machine without success, failing to notice that it was not plugged in.
Nigel Parker, medical equipment manager, told the inquest that the equipment had never been formally registered at the hospital, and so was not maintained. He said it was likely the battery had not been changed since 2008 when the hospital first received the machine.
Mrs Mason tried to use the wall suctioning equipment, unaware that this was connected to Mr Chipchase’s chest drain.
She told the inquest: “I could not get any suction. I turned it up – there was still no suction.”
She called for help before trying to use another piece of equipment – a foot pump – which also failed, because a piece of essential tubing was not connected and was in a drawer on a trolley.
Dr Robert Tooley, who was in his first year in a hospital as a fully trained doctor, told North East Hampshire coroner Andrew Bradley that Mr Chipchase was “clearly agitated and struggling to take a breath” when he arrived on the scene.
He noticed that the wall suctioning unit was attached to the chest drain but said he did not know how to swap this with the required high suction flow unit, which was within easy reach.
Julie Cairns, clinical services manager for medicine at Hampshire Hospitals NHS Founda-tion Trust (HHFT), told the inquest it was a case of unplugging one piece of equipment and plugging in another.
The inquest was told that there were healthcare assistants present who knew how to do this, but they were not asked to do so.
Healthcare assistant Clare Adams said that when she arrived at Mr Chipchase’s bedside, the medics were around him. She added: “They all looked to be in a state of panic.”
Despite a PSU being found in another ward, Mr Chipchase no longer had a pulse. Mr Chipchase was marked as a ‘do not resuscitate’ patient, and a decision was made to cease treatment.
Despite all of the errors, the inquest heard that it was almost certain that the blockage was not mucus, which could have been cleared by suctioning equipment.
Dr Michael Hall, who carried out the post-mortem examination, said tumour tissue had been growing through and infiltrating the trachea, which cannot be cleared with suction.
Mr Bradley recorded a narrative verdict, saying: “The trachea became blocked by tumour deposits and it could not be cleared.”
Giving a statement at the inquest, Rachel Murphy, one of Mr Chipchase’s three daughters, said: “Having devoted his career to the NHS, in particular Basingstoke hospital, he would have been pleased his death would have led to far-reaching improvements.”
Mary Edwards, chief executive of Hampshire Hospitals NHS Foundation Trust, said “I would like to extend my condolences to Mr Chipchase's family. As the coroner identified, the staff experienced difficulties with some of the equipment needed at the time of Mr Chipchase's death.
“A review identified changes which the hospital implemented immediately after the review.
“The issue with the equipment did not influence the outcome. However, it caused distress to the family and I wish to offer my sincere apology to Mr Chipchase's family for this."