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