Man died after heart monitor alert was 'silenced', inquest hears

A pensioner died in hospital after an alert from his heart monitor was 'silenced' by a member of staff, an inquest heard.

John Follon died while being treated at the University Hospital of Wales after a lead from the machine became disconnected, triggering an alarm at the nurses' station which was then switched off, a coroner was told.

The 78-year-old was not spoken to in person for another 30 minutes and was left without the monitor working for an hour and three quarters.

He was later found to be 'unresponsive' in a state of cardiac arrest and while doctors tried to resuscitate Mr Fallon, he sadly passed away.

In light of his death, a coroner has warned the Cardiff & Vale University Health Board that others may die in ‘similar circumstances’ at the hospital where nurses are still 'permitted to silence the alarm' at night to 'minimise noise'.

Assistant Coroner for South Wales Gaynor Kynaston said this means that if the alert then goes 'unnoticed', the risk that they will not be monitored for a lengthy amount of time 'remains'.

An inquest into Mr Follon's death heard the pensioner visited his GP with 'chest pains and breathlessness' on November 17, 2022.

After tests showed he had suffered a blockage in his right coronary artery, Mr Follon was taken in an ambulance to The University Hospital of Wales, Cardiff, where he underwent 'successful stenting' to remove the occlusion.

It was heard he 'made good progress' after the procedure to the point where he was 'independently caring for himself on the ward'.

But, his newly installed monitor showed a 'complete heart block' and a decision on whether he required a permanent pacemaker depended upon the extent of his recovery, it was heard.

For this reason, Mr Follon was being tracked on the Coronary Care Unit by telemetry, a monitor which displays a patient's heart rhythm and activity at a central nurse's station.

At at 6:57am on November 21, one of the leads became 'disconnected', triggering an alarm at the nurses station.

The inquest heard this alarm was 'acknowledged' at 7:04am - and was then 'silenced by a staff member'.

The evidence suggests that person did not check on Mr Follon at that time, the coroner said.

The pensioner was last spoken to around 30 minutes later, at 7:30am, before he was found 'unresponsive' in a state of cardiac arrest at 8:45am.

Despite trying to resuscitate Mr Follon, this was 'not successful' and he passed away.

Summing up the events, the coroner said: 'Prior to the cardiac event, a lead from the monitor had become disconnected, the alarm was silenced by a staff member who did not then check on Mr Follon leading to a period of an hour and three quarters during which he was not monitored.

'The cause of the cardiac arrest cannot be established and it is not possible to determine whether the lack of monitoring more than minimally contributed to his death.

'Neither the cause nor time of the cardiac arrest can be established as there was no monitoring during the period from when the lead became detached until his death.'

The coroner highlighted 'matters of concern' relating to Mr Follon's passing in a prevention of future deaths report.

He said while changes to the system 'have been made' - including making the alarm sound louder - in light of his death, 'it is still possible' for hospital staff to 'silence the alarm without checking on the patient'.

Mr Kynaston said when the alarm is triggered during a day shift, staff are required to check on the patient prior to the alarm being silenced.

But, during a night shift, staff are instead permitted to 'silence the alarm prior to checking the patient to reduce noise to a minimum while patients are sleeping'.

'The latter was the position in the instant case when Mr Follon's lead became detached,' he said.

'During a night shift, the circumstances in which Mr Follon died remain the same notwithstanding changes to nursing practice and the alarm system have been made.

'The risk of a patient not being monitored for a significant period of time remains and could give rise to a death in similar circumstances in the future.'

The coroner also that the monitors 'are not checked constantly' and that if a patients alarm is silenced, 'the risk that a patient will not be monitored for a significant period of time remains'.

He issued the report to Cardiff & Vale University Health Board, who have until December 8 to respond.