Hospital lost vital clues about tragic woman’s last moments

Jane Oram and Liam O'Hare
Jane Oram and Liam O'Hare
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The reasons why a woman died at Stoke Mandeville Hospital may never be known ­– because staff mislaid a machine containing vital data.

An inquest heard that a monitor which recorded 64-year-old Jane Oram’s vital signs prior to her suffering a massive heart attack went missing for two days after she died.

Surviving data showed an alarm on the ventilator providing air to Mrs Oram, indicating that it had become disconnected from her, had been going off for more than two hours .

Staff on duty at the time said they did not hear or see the alarm. And when healthcare assistant Carol Wright discovered the ventilator had indeed become disconnected, Mrs Oram was in a stable condition.

This was at 3.05am, more than two hours after the alarm supposedly started, and the inquest heard that it would not have been possible for her to survive this long without the ventilator’s assistance.

However, around 25 minutes later Mrs Oram suffered a massive heart attack. She died two days later on July 17, 2012.

Two nursing staff, deputy sister Mary Ann Dumdum and deputy charge nurse Firas Sarhan, have been suspended pending the outcome of an internal inquiry by Bucks Healthcare NHS Trust, which runs the hospital.

The trust has also taken action to improve training. It said in a statement: “This includes reminding staff in the unit about the detail within our observation policy for ventilated patients, as well as retraining being undertaken in the use of ventilation equipment and guidance re-issued about handovers and record keeping.”

Coroner Richard Hulett said a lack of concrete evidence meant he was unable to say for sure what happened.

Liam O’Hare, Mrs Oram’s husband, said: “Had that monitor been dealt with properly we would have got more information, we would have known what caused what.

“We’ve not got any answers because the answers are not available.

“That information was lost by the trust, either by carelessness or deliberately.

“We have to believe the nurses that the alarm did not go off. I don’t believe they did anything wrong.”

Mrs Oram had been in the spinal injuries unit at the hospital since January 19, 2012, having suffered a brain haemorrhage as a result of a heart attack which occurred after she had gone swimming.

Mr Hulett said it was impossible to rule if the fault lay with the machine or staff.

“Nobody has demonstrated to me a fault with this equipment, at all stages it has been found to be in working order. But I have no reason to suppose that the entire nursing staff have told a completely fabricated story.

“There is a monitor [which recorded her vital signs] and that piece of equipment was disconnected when Jane was taken to intensive care. It was put away in a cupboard.

“Once the battery had drained there was no way to examine that or retrieve any of that information.

“This is the inquest with the most contradictions that I have ever encountered.”

Mr Hulett concluded that Mrs Oram suffered a heart attack due to her brain injury and delivered a verdict of misadventure.