Coroner insists on oxygen training for paramedics
Coroner insists on oxygen training for paramedics after grandmother, 67, died when cylinder set fire to her home as ambulance crew treated her for suspected Covid symptoms
Lynn Hadley, 67, being treated by paramedics for suspected Covid symptomsOxygen cylinder sparked a blaze at her home in Walsall, on April 13 last year Grandmother could not be rescued and she died as a result of fatal burn injuries
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A coroner has insisted on oxygen training for paramedics after a grandmother died when a cylinder being used by ambulance staff set fire to her home, an inquest has heard.
Lynn Hadley, 67, was being treated by paramedics for suspected Covid symptoms at her home in Walsall, West Midlands, when the cylinder being used for oxygen treatment sparked a blaze on April 13 last year.
The 67-year-old’s husband Dave, daughter Kelly, granddaughter Mackenzie and the two paramedics were forced to flee from the burning house.
But Mrs Hadley, a former Tesco‘s worker, could not be rescued despite the efforts of her husband and she died as a result of fatal burn injuries.
Lynn Hadley, 67, was being treated by paramedics for suspected Covid symptoms at her home in Walsall, West Midlands, when the cylinder being used for oxygen treatment sparked a blaze
The 67-year-old could not be rescued despite the efforts of her husband and she died as a result of fatal burn injuries
The inquest heard how the grandmother had been suffering a high temperature, a suspected symptom of coronavirus, when her concerned family members phoned 999 for help, shortly before 5pm on Easter Monday last year.
The ambulance crew found that her oxygen levels were low and combined with breathing difficulties, they decided to give her oxygen, but the paramedic was not trained in accordance with manufacturer’s instructions for the sequence of opening the tank.
As a result a rare phenomenon known as ‘adiabatic compression’ occurred, caused by a rush of oxygen when a valve is opened quickly.
The German valve manufacturer VTI has since reported nine cases of ignition and was due to examine a further 20 regulators, although no defects had been reported up to January this year.
Last year Mrs Hadley’s husband Dave told how he saw a flash out the corner of his eye as the canister was turned on.
He said: ‘We called 999 because was Lynn was having a high temperature, unable to stand and was lethargic.
‘The paramedics arrived. They were wearing full PPE. The male paramedic asked Lynn a couple of questions while the female paramedic took her temperature.
‘The paramedics decided oxygen was needed and the female paramedic took an oxygen bottle and placed it on an armchair.
‘I saw a flash in the corner of my eye. I heard the paramedic that was next to the oxygen tank shout “Oh God”.
‘I saw sparks coming out of the cylinder and heard the gas start to ignite. The male paramedic tried to pull Lynn out of the way of the cylinder. The room was full of black smoke.
‘I saw fire across the floor. I managed to grab her arm but due to the smoke I had to get out to the garden.
Mrs Hadley’s family and the two paramedics were forced to flee as flames engulfed the property
The blaze in the house was caused by a rush of oxygen when a valve is opened quickly
Following the inquest a jury returned a verdict that the grandmother’s death was accidental and the ‘most likely cause’ was due to the build up of pressure caused by particles in the tank’s cylinder
‘We went into the conservatory and out to the front of the property. We tried to get back into the house. Police and fire crews then arrived at the scene.’
Following the inquest a jury returned a verdict that the 67-year-old’s death was accidental and the ‘most likely cause’ was due to the build up of pressure caused by particles in the tank’s cylinder.
The jury heard that the incorrect sequence had been used by a paramedic to open the cylinder which increased the chance of ignition occurring
West Midlands Ambulance Service University NHS Foundation Trust also apologised to Mrs Hadley’s family.
In his prevention of future deaths report sent to the Health & Safety Executive (HSE) and the Care Quality Commission (CQC), senior coroner Zafar Siddique stated: ‘In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
‘All agencies involved may wish to consider reviewing and issuing guidance for the operation and use of oxygen cylinders.
‘I am particularly concerned about the use of oxygen cylinders in the community in general and would invite the HSE and CQC to consider issuing further guidance urgently.’
A statement from West Midlands Ambulance Service University NHS Foundation Trust said: ‘This was an extremely rare event. As a trust, we immediately investigated what had happened and rapidly put measures in place to stop such an incident happening again.
‘We have also worked with a number of other agencies to ensure this learning is understood and acted upon on a national level.’
A copy of the report has also been sent to the Medicines and Healthcare products Regulatory Agency.
