When Guns are Outlawed, Only Outlaws will have Dead Batteries

dead-phone-batteryFirst, her batteries were dead. Then, she was.

The machine that was breathing for her set off an alarm when the power outlet failed, and the batteries took over; and a louder one when the batteries became critically run down. All a nurse needed to do was unplug it from the dead socket and plug it in a live one.

Despite several loud alarms designed to warn staff about the failing power supply, Jacqueline Scott passed away after the ventilator keeping her breathing shut down.

An inquest heard a nurse did not recognise the warning sound because no ventilator had ever ran out of power before.

The 55-year-old woman died later the same day at on the Richmond acute medicine unit at St George’s Hospital, in Tooting, south west London, last March.

A jury inquest at the Royal Courts of Justice heard Mrs Scott was on a ventilator plugged into a wall socket.

But the circuit providing the power had blown, meaning it was running on batteries – which eventually ran out, with several alarms ringing out before the power cut out.

The inquest heard Mrs Scott’s call bell was also faulty at some point.

And then, the excuses started. Remember this is England, where everyone gets care like the VA (sometimes great, sometimes not so).

Dr Renate Wendler, who led an investigation into the death, told the jury it was “not realistic” to expect nurses in the ward to know when power would have been interrupted to the plug sockets.

In front of the jury of six men and three women, she said: “The machine made a loud screeching alarm that no nurse had previously heard.”

“This noise must have been the final battery warning.”

“A lot of alarms had sounded on the machine. They were high priority alarms.”

Consultant anaesthetist Dr Wendler said the best nurses were looking after Mrs Scott, but that they reviewed the design of the machine and felt it was “not intuitive”.

She said: “I do not think the delay in calling for help had anything to do with the outcome of Mrs Scott’s case.

via Horror as woman dies when life support machine runs out of BATTERIES | UK | News | Daily Express.

All who think the government can do a great job on health care, open wide and say, “Arrgghhh.”

21 thoughts on “When Guns are Outlawed, Only Outlaws will have Dead Batteries

  1. Mr. 308

    “they reviewed the design of the machine and felt it was “not intuitive”.”

    No. No. No. Good gravy, they just pop off and blame the machine, the one component in this trail of failures that worked as it was supposed to.

    “But the circuit providing the power had blown”, what’s that? It just ‘had blown;, of course. Happens all the time to life support systems in hospitals. Have you ever been in a hospital and looked on the wall at the outlets? You see two sets, one plain and one in bright orange, or whatever the colour scheme is in that building. The brightly colored ones are fault tolerant outlets, backed up by a generator and hardened from failure.

    That’s to say, in a proper hospital, with properly designed circuits. The don’t ‘had blown’ and that is where your fault is, well that and staff that are either untrained, asleep, or whatever really happened.

    They blame the machine, the batteries and the alarms, of course to cover for state run hospitals and state employees.

    Just like they do over here for teachers, and DMV attendants, and corrupt politicians.

    Good gravy.

    1. Bloke_from_ohio

      DMV attendants in Ohio (BMV in buckeye vernacular) are private contractors. Or at least that is how it was explained to me by an acquaintance who worked there in college.

  2. Haxo Angmark

    “ohyeah? a strong blip? Don’t worry about it…it’s probably those B-17’s coming in from the mainland”

    – Command Center duty officer to Pearl Harbor radar operator at Opana Peak, c. 7:30 AM, 7 December 1941

  3. John Distai

    “Set Phasers On Stun” and “The Atomic Chef”. Hognose, read them. You will enjoy them (if you haven’t read them already).

  4. wheelsee

    Ummm, had they ever heard of BAGGING the patient???…EVERY patient on a vent is also supposed to have a bag for manual ventilator support in case something happens, or just so another can figure out the vent issue while the patient is till being cared for…..

  5. JAFO

    That’s the way the NHS rolls, and why socialized medicine only works if you are a party member with a sufficiently low party number, and then only kinda.

  6. Aesop

    Equal time for opposing views.

    Caveat: I am not a nurse in the UK, I am a nurse in the USA. So policy and procedure are probably somewhat different there, as well as duties and responsibilities.
    That said, the following:
    1) Ventilators do, in fact, put out a cacophony of sounds. Respiratory therapists, on this side of the pond, are the ducks who are extensively trained in understanding them, and maintaining the function of said machines. Not nurses, except accidentally, ever.
    2) Most of the time, a patient on a vent is attached to a machine making more noise than R2-D2 on the electronic version of crack, for any one of dozens of reasons. It occurs virtually every minute the patient is attached, to the point far beyond sensory overload.
    3) The display of information varies among every machine, from every maker, to the point that without intensive and specific training, anyone not a respiratory therapist would not readily grasp, nor be able to prioritize, what each note in the cacophony is intended to convey. Absent an actual trained member of the respiratory therapy department, the nearest equivalent is installing a pipe organ in the room, and assigning a capuchin monkey tethered to said organ to prance about the keys to the point of exhaustion. It isn’t, for example, as if the machine would helpfully have been standardized among any number of makers, models, or what have you, or that knowing a bit about one machine, you could easily take the time to try and troubleshoot any other of the breed.
    4) Respiratory therapists are eternally in short supply, everywhere and at all times, in every hospital I’ve ever been in, seen, or heard of, even under a medical care system here and not as thoroughly socialized (yet) as the abortion of care known as the UK National Health System.

    So in aviation terms, you had a device that looked about as intuitive as the engineer’s panel on a B-17, except labeled in Greek, with no such engineer anywhere handy, and with all the lights and bells sounding constantly, and thus conveying essentially zero information, to a person neither trained nor experienced in rapidly troubleshooting any of the plethora of alarms and noises.
    And the ground power to said panel, which normally did not, failed, and the batteries, which normally did not, also failed, followed by which the patient asphyxiated.

    If the nurse, doctor, nor anyone else handy didn’t also have the patient on telemetry, didn’t know nor notice, amidst the endless calliope of the ventilator’s death throes, that the actual patient – the point of the exercise – was breathing less frequently, and also getting concurrently less oxygen in their bloodstream than what is normally found when everything’s operating normally, then you could make a case that they should have noticed that – if the patient was attached to the requisite telemetry, if there was the equipment there to manually bag-ventilate the patient and deliver supplemental oxygen, and if the nurse wasn’t simultaneously assigned care of a number of actually “sicker” patients whose care she could temporarily abandon to step in and non-stop do the work of the failed ventilator, to breathe for the patient, while waiting for an RT with a fresh machine, if either said technician and equipment was, in fact,, readily available.

    But I don’t know what patient:staff ratios are or might have been at the incident or department of the hospital in question, or any of the other answers, and absent that information, trying to make this sound like nurse error is Stevie Wonder leading a backpacking trip through the Grand Canyon. Fun to watch, but joining, not so much.

    Why aren’t respiratory machines and their displays as standard as a car’s dash panel?
    Why are there eleventy-six noises and alarms, none of which can be shut off, to prioritize critical information from routine?
    Where was the requisite expert in the operation and interpretation of such specialized machinery?
    Was there any telemetry delivering basic patient information attached?
    Why was a plug failed, with no one capable of fixing it, or red-tagging it until such was done, and no one aware of that condition?
    Why did the back-up batteries fail?
    Those are just the first six most obvious culprits here.

    As in most aviation accidents, hospital deaths frequently involve a lengthy chain of errors and mistakes, and blaming the last person standing closest, in this case the nurse, is about like blaming all aviation disasters on “pilot error”:
    easy, convenient, self-serving for everyone but the accused, and generally a monumental load of horse cobblers.

    If it were in my power, everything in my world that honks, squawks, beeps, clangs, and whistles, to include family members, would be cheerfully beaten to death at the first moment they offended my ears, every shift, and the person(s) who inflicted and designed them, after a proper crotch-punching. I would love to be able to prioritize the things that make noise to the one to three things that actually matter, so that if they did go off, I’d know
    a) what it was, and
    b) that it was important, and then be able to set about fixing it.

    Unfortunately, no one, from the assholes who mis-design the offending hardware, to hospital purchasers of such horseshit, the administrators and clinical co-ordinators that implement it, nor anyone else, ever asks, let alone listens, to any input from end-users. Not once, ever, in a career.

    So you and yours are taken care of by entirely non-standardized machines, that emit an ongoing cacophony of worthless sensory overload, delivered in an under-staffed care model, with safe levels of both enough and the right skills sets of the requisite personnel purely a forlorn fantasy, in an increasingly mechanized system, and then the entire thing falls on its ass, and your granny dies.

    And to top it off, granny probably had ten bodily systems failing or in severe decline, had a chance in the single percentiles of ever having anything like recovery with any quality of life, but was being maintained on life support so that the long-neglectful family could feel better about the years of neglect of granny prior to that time, ignorance of the seriousness of her health conditions, and the utter futility of further care, and total denial of her probable end-state, despite the medical technology of the society she lived in. But that’s just an anecdotal guess, based solely on 98% of the ventilated patients I’ve seen over two decades here. YMMV.

    And then cared for in a failed socialist health care model by insufficient and overwhelmed staff, just for the cherry on top of the frosting.

    So maybe the nurse was to blame.
    Or maybe the health care system, the hospital, the staffing plan, the engineering department, the machine’s designers and manufacturers, the family, and the actual patient, had some wee bit of the blame to chug down as well…?

    Just saying.
    Flail away.

    1. Tierlieb

      In the end it falls on the shoulders of however is willing to accept the blame. Those are rare.

      That said, whenever I see hospital machinery, I wonder why they do not have a unified channel for error reporting. As you pointed out, several different machines used on one person, each with different diagnostic sounds – that is a user interface nightmare.

      Modularisation as a concept isn’t that new, is it?

  7. Aesop

    Both earlier attempted replies here vanished into digital limbo.

    So I blogged the reply I attempted on my page. Click over if you like.

    If not, the TL;DR answer is you have to get past at least six things before this gets to the nurse, probably more like ten, and while it’s fun to dogpile on the last person standing there, it’s in the same league as blaming all aircraft mishaps from 1903-present exclusively on “pilot error”: fun and easy, but wildly inaccurate.

    1. Buckaroo

      You made some excellent points, but when a machine that is delivering vital care to a patient is making a lot of unusual and puzzling alarm sounds for an extended period of time, isn’t it pretty obvious that you’d want to go find the person who is in charge of said machine? If for no other reason than to stop the annoying sounds? You can blame the system, the machines, and the shortage of appropriate personnel all you want, but the crux of the matter is, nobody within earshot of this thing felt any urgency to go outside the system, policies, and procedures and exhibit sufficient personal agency to deal with something that “wasn’t their problem”.

  8. Aesop

    Objection: relies on facts not in evidence.
    1) We don’t know how long a period of time the machine ran on battery power after the alarms started.
    Given that the power outlet it had originally been plugged into wasn’t working, presumably it could have been a very short time – a very few minutes, in fact – from first alarm to patient expiration, because the machine was probably never receiving ground power from the building from the time it was plugged in at that patient’s bedside. (Presumably, by “the person in charge of said machine”, whose exact job function would be to observe somewhere on the acreage of blinkenlights and spinning displays to see some objective proof that Tinkerbell, was in fact, alive, and the machine was being powered by the wall plug on that initial plug-in. That would make this entire episode the fault of “the person in charge of said machine”, from the get-go, BTW.)
    2) There may not, in fact, have been any such “person in charge of said machine” anywhere available in that post-alarm interval.
    3) For bonus stupid points, the plethora of alarms may have depleted the battery even faster than normal, hastening the demise of the patient.
    4) Going “outside the system, policies, and procedures” in a health care setting, like many others where there is a license to practice involved, and copious binders full of P&Ps, is the short cut to being fired, sued, having your license revoked for cause, and then doing prison time. As Casey Stengel used to say, “You could look it up.”
    It is thusly seldom the recommended response.
    5) If “nobody in earshot of the thing” is trained, charged with, nor responsible to troubleshoot the problem, that doesn’t de facto make it the fault of the nearest bystander, any more than leaving a ticking time bomb on someone’s desk suddenly qualifies them as an EOD technician. Nor does it demand that they be expected to fall on that bomb or carry it to an open space personally, for the good of everyone else.

    So, when you desperately need someone present whom you don’t have, upon whose shoulders does responsibility for the lack of such personnel fall?

    The system there IS the entire problem. It’s unrealistic to expect the nurse to pull hitherto unknown specialist expertise out of her @$$ to compensate for the manifest multiple shortcomings of the NHS, and for exactly the same reason that pilots don’t shinny out on to a wing to repair engines in flight.

  9. Aesop

    Objection: relies on facts not in evidence.
    1) We don’t know how long a period of time the machine ran on battery power after the alarms started.
    Given that the power outlet it had originally been plugged into wasn’t working, presumably it could have been a very short time – a very few minutes, in fact – from first alarm to patient expiration, because the machine was probably never receiving ground power from the building from the time it was plugged in at that patient’s bedside. (Presumably, by “the person in charge of said machine”, whose exact job function would be to observe somewhere on the acreage of blinkenlights and spinning displays to see some objective proof that Tinkerbell, was in fact, alive, and the machine was being powered by the wall plug on that initial plug-in. That would make this entire episode the fault of “the person in charge of said machine”, from the get-go, BTW.)
    2) There may not, in fact, have been any such “person in charge of said machine” anywhere available in that post-alarm interval.
    3) For bonus stupid points, the plethora of alarms may have depleted the battery even faster than normal, hastening the demise of the patient.
    4) Going “outside the system, policies, and procedures” in a health care setting, like many others where there is a license to practice involved, and copious binders full of P&Ps, is the short cut to being fired, sued, having your license revoked for cause, and then doing prison time. As Casey Stengel used to say, “You could look it up.”
    It is thusly seldom the recommended response.
    5) If “nobody in earshot of the thing” is trained, charged with, nor responsible to troubleshoot the problem, that doesn’t de facto make it the fault of the nearest bystander, any more than leaving a ticking time bomb on someone’s desk suddenly qualifies them as an EOD technician. Nor does it demand that they be expected to fall on that bomb or carry it to an open space personally, for the good of everyone else.

  10. J

    “Despite several loud alarms designed to warn staff about the failing power supply, Jacqueline Scott passed away after the ventilator keeping her breathing shut down.”

    When I read this, my mind said, “place your bets, I am going with the UK.”

    I read on. The article was, of course, about the UK. The guess was not dumb luck.

  11. Docduracoat

    Aesop,
    You are 100% right about the alarms being more of a problem
    Since they are not standardized, and they are always going off, staff quickly learn to ignore them.
    We have surgeons who demand we silence them as it is so annoying how many alarms go off in every routine case.
    We in Anesthesia have been trying for years to increase patient safety by standardizing all displays and alarms.
    Unfamiliarity with different machines continues to lead to needless patient deaths.
    The latest direction is safety is to engineer it so the human cannot make a mistake.
    We finally got the authorities to mandate that I.V. Syringes will not fit oral or epidural tubing.
    The diameter index safety system and pin index safety system are mandated so that the different breathing machines and gas tanks only fit together one way.
    And people have actually deliberately machined adapters or sawn off pins so they could assemble it the wrong way as told by their supervisors!
    The tanks are supposed to be standard colors, and people are still painting tanks and confusing others with what’s in them!
    The standard for battery back up is that it should funtion for 30 minutes.
    Pulse oximetry is the last monitor that tells you it is time to bag the patient.
    Those declining tones are the sound of the beating of the wings as the angel of death approaches.
    If you hear those sounds…call Anesthesia!

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