Oxygen tank not turned on, patient dies: Coroner calls for stricter safeguards
Published on Jul 30, 2014 4:45 PM
SINGAPORE - The state coroner has called for stricter procedural safeguards when patients dependent on ventilation equipment are moved from one place to another, following a "medical misadventure" that led to the death of an elderly patient a year ago.
These include closely monitoring the patient and devices tracking his vital signs when he is placed on the equipment, instead of other "subsidiary" tasks, and retesting the machine on-site beforehand.
Neither had been done before Madam Ramasamy Krishnama, 83, went unresponsive while being transferred to Mount Elizabeth Novena hospital on the evening of July 8 last year.
Shortly after being moved from her Tan Tock Seng Hospital bed to an adjacent trolley and put on a portable ventilator, her level of oxygen saturation became "unrecordable" because a transfer team had failed to turn on an oxygen tank that was supplying the ventilator.
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