Young woman with disabilities admitted to hospital with breathing difficulties and given wrong oxygen levels

What happened

In summer 2010 Miss B was admitted to hospital with breathlessness. She was placed on a paediatric ward despite being a young adult because she was familiar with it and staff knew her. Staff gave her oxygen but a specialist did not see her for seven days. When she was seen, a cardiologist suggested giving her oxygen saturation levels for a patient of Miss B's age, but staff could not manage these levels on the paediatric ward, because of her weight, age and their being used to managing children. Staff didn't realise how important the specified oxygen levels were, and Miss B continued to be over–oxygenated (at a level usually used for children), which worsened her condition.

Also, in investigating her symptoms, the respiratory consultant said that Miss B's obesity and scoliosis (abnormal curvature of the spine) would 'not usually' cause low oxygen levels. Because her oxygen levels were not recognised, the consultant did not take appropriate action, which would have been to transfer her to an adult unit for other, long–term, treatment.

Some 14 days after Miss B had been admitted, a physiotherapist noticed her sleep apnoea condition (sleep apnoea causes breathing interruption when a person is sleeping). Staff had missed this when they had previously investigated Miss B's condition, and it was one of the reasons for her low oxygen levels. This led to a further delay in suitable treatment. Five days later, Miss B was moved to a more suitable adult ward at another hospital where staff were more able to manage her low oxygen levels.

Miss B died 11 days later from respiratory failure and infection.

What we found

Miss B was inappropriately placed on a paediatric ward where staff were unfamiliar with the adult guidelines for her care.

There was fault in the seven–day delay in getting a cardiology and respiratory opinion and diagnosis.

There was fault in the respiratory consultant's opinion that Miss B's existing conditions would not be affected by the higher levels of oxygen she received on the paediatric ward.

There was also fault in overlooking Miss B's sleep apnoea for 14 days, and the two–week delay in proper treatment.

Miss B was left in prolonged unnecessary discomfort and suffering. Ms A was also left in great distress watching her daughter's decline without an explanation of her diagnosis and treatment.

Putting it right

The Trust apologised to Ms A for the faults we identified and paid her £1,000 in recognition of her distress. It has completed an action plan to address the faults found.