A retired headteacher who was being treated in hospital for Covid died after an oxygen tube connected to his face mask came away in a mystery tragedy, an inquest has heard.
James Johnson, 83, of Ffordd Elfed, Wrexham, died in January 2021 at Wrexham Maelor Hospital.
The widower had been a patient during one of the major waves of Covid.
Respiratory consultant Dr William Jones told the Ruthin inquest he'd never come across a tube being disconnected before. Mr Johnson's fatal decline would have occurred in a "small number of minutes."
A post-mortem examination showed Mr Johnson had Covid pneumonia.
Dr Kath Clarke, assistant director for patient safety who chaired a serious incident review for the health board, said the tube becoming disconnected from the mask was "really, really unusual and still is."
No fault was found with the continuous positive airway pressure (CPAP) machine. It was possible Mr Johnson may have leaned on the tubing but the investigation into the tragedy was unable to decide what happened.
A nurse and a healthcare support worker, wearing personal protective equipment, were looking after eight patients in two rooms. Ideally there should have been two patients to one nurse.
'There was something not right'
Nurse Catherine Norgrove said patients were observed through windows and the "obs" machine was turned so the screen could be seen. But when no-one had been in the rooms, machine alarms couldn't be heard.
At 1.30pm she looked at Mr Johnson's monitor. "I felt there was something not right," the nurse said. A doctor then told her the tubing wasn't attached.
Coroner John Gittins said Mr Johnson had been admitted to the hospital on January 3 2021 and treated for Covid. A week later his declining condition required CPAP respiratory support.
Due to the pressures of the pandemic it was given using a machine normally used for home care.
The coroner said: "On January 13 staffing pressures meant that only two members of staff had been fit tested, allowing them access to the room where Mr Johnson was being cared for. Together they had to care for eight patients, whereas optimum care in a non-pandemic scenario for CPAP patients would have been one nurse to two patients."
It was then noticed that the pensioner's oxygen saturations had dropped and after his death it was realised that an oxygen tube which fed into the CPAP mask was no longer connected.The coroner remarked: "It's not possible to establish how the oxygen tube had become disengaged. However, the reduction in the delivery of oxygen to Mr Johnson would have led to increasing hypoxia and it is probable that this would have hastened his death."
Recording a narrative conclusion, the coroner said it was a rare situation at a time when the NHS was under "severe" pressure.
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