A coroner’s report found that a 10-minute power outage at Scunthorpe General Hospital delayed life-saving treatment and contributed to the death of 77-year-old Jean Dye.
By Alyx Arnett
A woman died at Scunthorpe General Hospital in England after a power failure delayed treatment for a complication during a heart procedure, a newly released coroner’s report has revealed.
Jean Dye, 77, experienced an artery dissection during a percutaneous coronary intervention on Sept 7, 2020. The complication was rare but recognized, and doctors prepared to place a stent to repair the injury. At that moment, however, a power failure occurred, cutting power for about 10 minutes and disabling the X-ray imaging needed to carry out the procedure.
Although power was eventually restored and the stenting completed, Dye did not recover. “On balance of probabilities, Mrs Dye would have survived but for the loss of electrical power,” senior coroner Paul Smith writes in the report.
The report says the outage was caused by activation of the Emergency Power Off (EPO) circuit, which overrode backup power. There was no manual activation of the EPO buttons. A fault within the circuitry was suspected but could not be confirmed.
In a Regulation 28 report to prevent future deaths, Smith raised concerns that the catheter lab lacked both an indicator to show the EPO circuit had activated and an internal restart switch. Engineers had to be called to a plant room elsewhere in the hospital to restore power.
“Had staff been aware of the exact cause of the loss of power on this occasion and had they had the opportunity to reset the circuit without the need to await the arrival of an engineer…the downtime would likely have been significantly reduced,” Smith says in the report. “Whilst it was not possible to say that the additional time spent on this occasion made a difference between the patient surviving or not, there may well be future cases within which such fine margins are time critical.”
The coroner notes that while accidental activations of EPO circuits are rare, they have occurred nationally. He called for NHS England and the Health and Safety Executive (HSE) to review where EPO controls are placed and whether additional staff training is needed.
NHS England and the HSE have until Aug 28 to respond to the report.
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