Inquest Into Peter Knight’s Death Concludes

The family of a King’s Lynn man who died in Queen Elizabeth Hospital after problems during a routine ward transfer have spoken out following an inquest into his death.

Peter Knight, who suffered from a lung condition meaning he was oxygen dependent, was admitted to the hospital in the early hours of 5 June last year with a chest infection. 

While his condition improved with antibiotics, doctors advised he should stay in hospital for further care and subsequently arranged the next day for him to move from the Medical Assessment Unit to the Necton Ward. However, Mr Knight was connected to a non-portable oxygen system and received no oxygen during the transfer. His condition significantly deteriorated and he passed away a few hours later on the Necton Ward.

Following Peter’s death his family instructed expert medical negligence lawyers at Irwin Mitchell to investigate his care under The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust and support them through the inquest process.

An inquest into Peter’s death held at King’s Lynn Magistrate’s Court this week heard how before the transfer, Peter’s wife Donna had told the porter and nurse involved that his oxygen levels could not fall below 88 per cent. 

However, as Peter was moved he started to gasp and upon his arrival at the Necton Ward his levels were found to be significantly lower. Senior Coroner, Jacqueline Lake, noted that these saturations were around 38-39 per cent. The Coroner heard how there were two oxygen systems, and that the nurse transferring Peter had confused these. 

The Hi-flow system which is not portable and has to be connected to an electrical supply at the wall to function, was instead connected to the portable cylinder, meaning that Peter had not received any oxygen at all during the transfer. Oxygen was given on arrival at Necton Ward which improved the saturations, but these never recovered, and he sadly died a few hours later.

The Coroner noted in her summing up that the oxygen levels had been stable prior to the transfer and it was heard from one of the nurses on the Necton Ward that on arrival to the ward Peter was gasping with breath and nearly unconscious.

A conclusion of death by accident was recorded at the inquest, with the Coroner noting in her summing up that the lack of oxygen during transfer caused or more than minimally contributed to his death.

As a result of this incident the Trust have taken steps to try to prevent a future incident occurring. This has included the re-training of staff, and a review of their transfer policy, which is still ongoing. The Coroner has asked the Trust to report back at the end of March 2019 to the Coroner and the family with an update and to confirm what progress has been made. 

Sophie Bales, specialist medical negligence lawyer at Irwin Mitchell’s Cambridge office who is acting for Peter’s wife Donna, said after the hearing: “This is a truly devastating case with the inquest sadly highlighting how there were clear failings in relation to the care that Peter received.

“The family recognise that initial steps have been taken by the Trust, including a review of the Transfer Policy, to try to ensure that this does not happen again.  

“The Trust is required to write to the Coroner regarding progress made with this by the end of March and we will ensure to follow this up with them. 

“We hope that our efforts will ensure that the NHS and other healthcare providers learn lessons from this truly awful case.”

Donna said: “We are very pleased that the Coroner has highlighted that the lack of oxygen was a significant cause of Peter’s untimely death and pleased that the Coroner has asked the Trust to report back in March 2019 to confirm the progress that has been made.

“As a family we are concerned to ensure that no other family has to go through what we have. We now hope to move on and remember all of the good times we had with Peter.” 

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