Patient died at Sheffield hospital after being starved of oxygen

Simon Harper was admitted to the Northern General Hospital on March 6 last year with jaundice and a swollen stomach.

The 55-year-old, from Stoneley Crescent, in Birley, Sheffield, was moved to intensive care when his condition deteriorated the following day, but his portable oxygen cylinder was not switched on during the transfer.

The lack of oxygen is believed to have caused his heart to stop en route, and although he was resuscitated his condition continued to decline and he died two days later.

An inquest found Mr Harper had died from multiple organ failure, pneumonia and alcohol-related liver disease, and concluded it was not possible to state what part if any the cardiac arrest had played in his death.

But Sarah Slater, assistant coroner for South Yorkshire, warned in a subsequent report that the error raised concerns about training at the hospital.

"In my opinion there is a risk that future deaths will occur unless action is taken," she wrote in a report to health secretary Jeremy Hunt sent last November but only just published.

An inquest last October heard how responsibility for supplying oxygen to patients being transferred was switched in November 2010 from porters to nurses.

Only one training session was provided to a small number of nursing staff at the time, after which the hospital relied on 'peer to peer' training.

Sheffield Teaching Hospitals, which manages the Northern General, said at the time of the inquest that it held no record of which staff had received relevant training.

Ms Slater's report states: "The secretary of state for health is asked to consider whether it is appropriate for training to be provided and documented regarding the use of portable oxygen cylinders for patients.

"The implementation of a transfer of patients policy should also be considerde as those available did not cover the issue.

"In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action."

Sheffield Teaching Hospitals apologised for the error and said although this was not found to be the cause of death it had nonetheless taken the incident 'very seriously' and tightened up safety measures following an investigation.

Dr David Throssell, medical director at the NHS foundation trust, said: "We always strive to provide the highest possible care to all our patients and so it is with deep regret that a genuine human error was made regarding the oxygen supply to Mr Harper during his short transfer to critical care.

"Whilst this was not deemed to be the cause of death for Mr Harper, we have nevertheless taken the incident very seriously and fully investigated what happened.

"As a result we have improved the training, documentation and processes regarding oxygen being used during the transfer of a patient. I would like to reiterate once again how sorry we are that this happened."

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