Patient died after he was starved of oxygen during ward transfer

A HOSPITAL'S system for transferring seriously ill patients was "defective" and contributed to the death of a patient in 2009, a sheriff has found.

John Aitken, 56, died at Dumfries and Galloway Royal Infirmary after an attempt was made to move him between wards.

A fatal accident inquiry yesterday found there were several "defects in the system of working" contributing to his death.

However, the sheriff said that Mr Aitken was "very ill" at the time and that none of the precautions outlined to the inquiry would have guaranteed survival.

Mr Aitken was admitted in July 2008 and diagnosed with an oesophageal tumour.

He was later taken to Edinburgh Royal Infirmary, but returned to the Dumfries hospital's acute rehabilitation ward in September that year after experiencing complications. He was also suffering from a pressure sore and partial paralysis.

Despite experiencing pain and discomfort, the patient was said to have remained "stoic" and firmly wished to get better and return home to his "highly supportive" family. However, in March 2009, his condition deteriorated and the decision was taken to transfer him to the intensive care unit on 1 April.

He died the same day after an attempt was made to move him from ward 14.

Sheriff Kenneth Ross, who heard the inquiry over five days at Dumfries Sheriff Court, formally recorded cardiorespiratory arrest among the causes of death. He also outlined several "reasonable precautions" which might have avoided Mr Aitken's death.

They included switching on a portable oxygen supply after he had been disconnected from the wall-mounted oxygen supply.

Sheriff Ross wrote in his determination: "Mr Aitken was deprived of oxygen during the transfer. A supply of oxygen might have avoided the cardiac arrest which led to his death. It follows that switching on the supply was a reasonable precaution which might have avoided the death."

He also noted "defects" in the system of working which contributed to Mr Aitken's death.

He said there was in the hospital, at the time of the death, "no formal, properly publicised and fully understood procedure for the care of ill patients during transfers between wards".

A spokesman for NHS Dumfries and Galloway said: "The (health] board has reviewed the detailed determination of Sheriff Ross and fully accepts his findings.

"As Sheriff Ross acknowledges in his determination, a detailed review of Mr Aitken's death was carried out immediately and a range of measures put in place to improve systems.

"The sheriff accepts that the measures put in place by the board have addressed the weaknesses identified and, therefore, has made no specific recommendations in his determination."