16 minutes before staff realised patient was dying

A WOMAN bled to death after her kidney dialysis machine became disconnected, a coroner has found.
Coroner Jane Hendtlass wants a review of machine connectors following the death of Judith Heath in 2006.

Mrs Heath, 68, was at The Alfred hospital in Melbourne for routine dialysis when a nurse found her unresponsive and leaking blood on the floor.
Ms Hendtlass said Mrs Heath was found 16 minutes after the machine became disconnected.

"Mrs Heath's blood continued to pump out of her body ... it seems that the pump continued to operate for about 16 minutes after the disconnection occurred," she said.

"The disconnection between Mrs Heath's blood supply and the haemodialysis machine did not trigger the alarm or stop the pump ... and this failure caused her death."

Mrs Heath was resuscitated, but suffered irreversible brain damage and died the next day.
A subsequent check of the machine found no problems.

Connection malfunctions have been documented with causes including failure to properly twist-lock them, and cracking and breaking.

The Alfred has since changed its procedures to reduce the risk of human error contributing to disconnections. Ms Hendtlass recommended the Therapeutic Goods Administration review standards of connectors.

 

 

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