'Catastrophic' consequences after oxygen error

A review found a cylinder had not been prepared correctly, resulting in no flow of oxygen to the patient

A patient in north Wales suffered "catastrophic" consequences when staff didn't connect their oxygen supply correctly.

The Betsi Cadwaladr health board, which was caring for the patient at the time, is investigating and says it was one of a small number of recent similar incidents.

But it refused to say whether the patient died, or to explain what the “catastrophic” consequences were.

It says it is working to improve staff training to avoid similar incidents happening again.

On Tuesday, Wales' health minister Eluned Morgan said the health board still had "a lot to do," before it could be taken out of special measures.

A report to the committee said: “Further patient safety incidents have occurred in the health board related to the preparation and administration of oxygen using portable cylinders.

“On review, the cylinder had not been prepared correctly, resulting in no flow of oxygen to the patient.

“One incident had a catastrophic outcome and is under investigation.”

Geoff Ryall-Harvey from the patients’ watchdog body Llais said: “how did this happen in the first place? The report isn’t clear on that.

“It isn’t cutting edge medical science – it should be everyone’s basic knowledge who touches that equipment to ensure that oxygen is flowing.

“It’s extremely worrying, which is why we at Llais will be following this up and asking what the health board is doing to stop it happening again."

Angela Wood, director of nursing at the health board, said: “In this case, a small number of incidents were reported with the operation of portable oxygen cylinders.

“These require complex operation in order for them to deliver oxygen.

“We are investigating one ‘catastrophic’ outcome related to no flow of oxygen but I’m unable to give any more detail than that included in the report due to confidentiality concerns.

“We have re-issued guidance on the correct operation of these cylinders and the health board is strengthening training to go alongside the competencies which already exist.”

The same meeting of the health board’s Quality, Safety and Experience Committee will also hear about a backlog of hundreds of test results and letters referring patients for treatment that were not sent out for months.

It happened in the urology department, which deals with the kidneys, bladder and prostate.

The health board has admitted that in a small number of cases, patients may have been harmed by the delays, some of which dated back as far as March 2023.

Angela Wood added: “We have identified administrative processes which resulted in information not being shared between specialties and GPs in a timely manner.

“We have identified cases of potential harm and we are investigating. Any patients affected by this are being contacted.

“We have carried out a review of all specialties to make sure this has not been repeated elsewhere within the Health Board - the initial review did not show any similar issues.

“I would like to sincerely apologise to all patients affected and assure them that, unless contacted with specific information, they should not worry.”

Next week will mark a year since Betsi Cadwaladr was placed under the highest level of Welsh government oversight.

Discussing the wait for treatment in north Wales, health minister Ms Morgan said: "I do appreciate that people are still having to wait for too long, but things are moving in the right direction.

"The health board has been in special measures for 12 months and there is still a lot to do.

"Last year I set out a series of sustainability conditions for the board which are still valid and will need to be met before de-escalation... can be considered over the next few months."