Faulty dialysis machine kills patient with 6 liters of extra fluid

[RightSide]

Thursday, Apr 29 2010 6AM  11°C 9AM 16°C 5-Day Forecast
Patient dies after faulty dialysis machine pumps six litres of liquid into his body

By Daily Mail Reporter
Last updated at 4:15 PM on 27th April 2010

A kidney patient has died after a faulty dialysis machine pumped six litres of liquid into his body for 45 minutes.

An inquest into the death of David Brailsford, 52, heard that nurses at the former Derby City General Hospital had been aware the machine was broken, but continued to use it as normal while waiting for an engineer to arrive and inspect it.

Father-of-two Mr Brailsford, who had suffered long-term kidney problems, despite having undergone a transplant, died less than a month after receiving the dialysis.
The former Derby City General Hospital, where Mr Brailsford received dialysis from the faulty machine

The former Derby City General Hospital, where Mr Brailsford received dialysis from the faulty machine

Two experts told the inquest they were surprised the strain on Mr Brailsford's heart, caused by the volume of liquid being pumped into his body, had not killed him sooner.

Derby coroner Dr Robert Hunter said: 'On May 28, 2008, Mr Brailsford had entered for routine dialysis and had been transfused with six to eight litres of fluid over 45 minutes.'

When asked what effect this would have had on Mr Brailsford, Dr Martin Mansell, a kidney expert from the Royal Free Hospital in London, replied: 'I would have expected it to have killed the patient.

'I suspect the volume was nearer eight litres than six.

'To add that amount of fluid to the circulation in a 45-minute period, bearing in mind that the circulating blood volume is only about five litres, it represents, in my opinion, a massive fluid load.

'An eight-litre infusion in a 45-minute period to a normal person would have been enough to put them into acute heart failure.'

He said he suspected the reason it had not caused instant death was because kidney patients often built up tolerance to extra fluids in their bodies.

Hospital staff said they were aware of a fault on the machine but thought it was a minor problem with a timer.

Mr Brailsford was on dialysis and had to visit the hospital three times a week.

Before a patient undergoes dialysis treatment, a special fluid is used to clear the tubes of air.

But the court heard that, after painter and decorator Mr Brailsford was hooked up to the machine, it pumped the fluid into his body.

Dr Jonathon Panting, a heart expert from Good Hope Hospital, Sutton Coldfield, also told the inquest that he, too, believed this may have been the reason Mr Brailsford did not die straight away.

He said: 'I would have expected him to have died very quickly indeed.

'That didn't happen. He went into heart failure. Treatment was given to get rid of the excess fluid.'

The inquest at Derby and South Derbyshire Coroner's Court yesterday heard that the medical cause of Mr Brailsford's death was scarring of the heart.

Dr Panting said that Mr Brailsford had suffered previous heart problems but there was increased strain because of the fluid transfusion.

Mr Brailsford's wife, Linda, of Derby told the inquest that although her husband had been unwell he was still active and was 'looking forward to the better weather'.

She said his condition gradually deteriorated after the transfusion and he died on June 21, 2008.

She added: 'He started to wither a little bit, a bit like a plum becomes a prune,'

She told the court that on May 29, 2008, the day after the incident, a doctor had told her husband that 'the machine had been faulty and that there would be an inquiry'.

She said: 'We heard nothing more at all.'

Mrs Brailsford later contacted the hospital which resulted in a member of staff calling her to reinforce the message about the faulty machine.

Glynis Salt, a clinical technical officer at the hospital's renal unit, who was looking after Mr Brailsford, said the machine had failed to start counting down time at the beginning of the dialysis session.

The inquest heard Miss Salt and several other members of staff examined the machine but could not find the cause of the problem, so they waited for an engineer to arrive.

When asked by Dr Hunter why no one stopped the machine, she said: 'I don't know.'

Miss Salt also admitted there was no entry in the nursing notes about the fault with the machine.

Nurse Andy Byers, another of the staff responsible for looking after Mr Brailsford, also told the inquest that a timer had not been working on the dialysis machine but he did not realise anything else was wrong.

He said: 'I thought it was a minor problem that the technicians could solve.'

The hearing continues.

 

[galvo]

Terrible! Incompetant bastards!!

[Jean]

That is outrageous!!!! Evidently no one was even watching out for the poor guy. How sad that some one had to die due to incompetence.

[Stacy Without An E]

I'm surprised this doesn't happen more often considering the all-over-the-map quality of the personnel at Dialysis centers across the nation.  Sometimes as patients, we're hooked up and then simply left alone, unchecked, for two to three hours.

I know there have been numerous times I've been cramping or bleeding and there wasn't a member of the staff anywhere to be found.  We have those hospital buttons next to our chairs, but the staff always ignores them, so they're useless.

Everyone on the medical staff, in administration, and sitting on the board of directors should be removed and the center should be closed until ALL the issues can be addressed.

And my heart goes out to his family, who were served a gross injustice.

[sullidog]

I hope his wife sues the hell out of them.
The excuse for staff not being around at our center is the famous, we're under staffed, Yeah our health is in your hands and you are understaffed and can't look out for us?
Please send us an update if you have one.
Troy

[Rerun]

I don't understand how he could just get fluid.  I mean if it wasn't saline ( which you only get 1 bag) then it was water from the back?  I guess I don't understand how that could happen?

[Adam_W]

I don't understand how he could just get fluid.  I mean if it wasn't saline ( which you only get 1 bag) then it was water from the back?  I guess I don't understand how that could happen?

That's just what I was thinking. The article said something about "special fluid to prime the tubes", which would be saline, but like you said, there would have only been one bag and last time I checked, saline doesn't come in six litre bags! I wish I knew what kind of machine it was because I do not understand how this could have happened. However it happened, as we all know it should have never happened. I mean they KNEW the freaking machine was broken! These clowns deserve to get their asses sued off by this man's family.

Adam

[RichardMEL]

yeah I had the saline bag emptied into me twice in pne month which I was NOT impressed about, but it only adeed about 600ml or so, which sucked totally, but at least i could live with it. I am shocked reading this article...

[YLGuy]

One thing that concerns me is all the alarms going off in my unit that are ignored by staff. 

[Rerun]

I've printed off this article to take into our biotech to see if he can tell me more on how this could happen.

         

[Bajanne]

I just finished reading this for the guy in charge of maintenance in our unit!  It was rather unnerving to read.

[Zach]

This news article seems to be from the U.K., which sometimes uses a different type of dialysis machine, known as hemodiafiltration.  It works like this:

http://www.fresenius.de/internet/fag/com/faginpub.nsf/Content/Hemodiafiltration+(Caring+for+Health)

As a high volume of fluid is removed from the patient, an ultra-pure solution is infused.

According to the article, the man was over-infused on May 28, 2008, but died on June 21, 2008.  Maybe it's a misprint, and he died on June 1st.

A very poorly written article about another tragedy.

[Rerun]

Nice catch Zach!

             Makes sense now!       

[Bill Peckham]

This news article seems to be from the U.K., which sometimes uses a different type of dialysis machine, known as hemodiafiltration.  It works like this:

http://www.fresenius.de/internet/fag/com/faginpub.nsf/Content/Hemodiafiltration+(Caring+for+Health)

As a high volume of fluid is removed from the patient, an ultra-pure solution is infused.

According to the article, the man was over-infused on May 28, 2008, but died on June 21, 2008.  Maybe it's a misprint, and he died on June 1st.

A very poorly written article about another tragedy.

 

That could be it but I think on a standard machine if the trans membrane pressure were reversed water from the dialysate could cross the membrane.

[okarol]

Why we have a right to know if anyone will answer for the death of David

KIDNEY patient and father-of-two David Brailsford died because staff failed to stop a faulty dialysis machine pumping up to eight litres of fluid into his body.

Royal Derby Hospital has not revealed whether disciplinary action has been taken against those involved. Here Paul Pegg, 63, of Mackworth, whose late wife Jill had dialysis, tells why patients have a right to know.

Four hour after hour, week after week, my beloved wife, Jill, put her life in the hands of the staff on Derby's dialysis unit.

Now a coroner has found that some members of that team failed to turn off a machine which killed David Brailsford.
Click here for more

I find it difficult to put into words the emotions that this tragedy has triggered in me, but here are a few – anger, deep sadness and fear.

There is little anyone can do to get rid of my anger and sadness.

But it is in the power of the hospital's managers to get rid of my fear.

It is a fear that staff are not disciplined for making mistakes and so are not encouraged to learn lessons from their failings.

That fear would be put to rest if I knew action had been taken.

Imagine this were the private sector, a local factory, for example, where there had been a fault with a machine.

In that instance, the person responsible would surely have been dismissed or disciplined.

That sort of action should have been taken here and the people of Derby have the right to know whether it has.

If we are not told, then many people, myself included, will be left believing that no disciplinary action has been taken.

Jill had a rare condition which led to kidney failure and she used to go to the unit three times a week.

Her trip would not just last for the four hours it takes to have dialysis, it would be an all-day event.

We would get up at 5.30am and, by the time Jill had been weighed and dialysed and her bleeding had stopped, it would often be late afternoon.

With so much of our time revolving around the dialysis unit, it was vital for both of us that we felt comfortable with the care available there.

The same applies to hundreds of kidney patients and their families today. Some patients are in hospital for eight hours, or even longer, and they want to be in an environment where they feel safe.

Which is why it is an outright disgrace that they have not been told whether staff have been disciplined.

I know there are staff working on the unit who really want to make a difference to the lives of patients.

And I understand that nobody is infallible, let's get that straight.

This isn't a witch hunt. But patients want to feel confident that when staff make mistakes, they learn from them.

That is what disciplinary action would lead to.

No matter what walk of life you're in, when you get in trouble you watch your back and make sure you do everything by the book.

People need to know if somebody has been pulled up for failing to do their job.

The hospital says that staff have been retrained, but some of them are very long-standing so, in my view, training is not enough.

If they don't know the job by now, that should lead to more than just retraining.

A lot of patients will be frightened to raise their concerns because they have to spend an awful lot of time on that unit.

They see the same staff on a regular basis so they don't want to criticise them.

But I don't need to visit the unit any more and I'm not afraid to say what I think.

So here is my message to the hospital's directors: "Be open with the people of Derby and restore faith in your staff in the wake of this terrible tragedy."

Paul Pegg is former treasurer of Derby and District Kidney Patients' Association and former general secretary of charity Stuart Strange Vasculitis Trust, which deals with rare illness.

http://www.thisisderbyshire.co.uk/news/right-know-answer-death-David/article-2086511-detail/article.html

[Rerun]

I think it depends on the person.  There are some techs that are just screw offs, so they may not learn from their mistakes, but there are others that take their job serious and if someone died on their watch would be harder on themselves then the company could ever be.

Still doesn't say how the machine malfunctioned?  Was it a hemodialysis machine or a hemodiafiltration machine?
Was it transmembrane pressure? 

[RightSide]

I'm surprised this doesn't happen more often considering the all-over-the-map quality of the personnel at Dialysis centers across the nation.  Sometimes as patients, we're hooked up and then simply left alone, unchecked, for two to three hours.

That has never happened at my center, in the two years I've been going there.  There is always at least one staff member present at all times.  Usually there are at least two.  And they come around periodically to check the machines.