4.9 The difficulties the staff encountered with the oxygen equipment were indicative of a lack of appropriate checking and maintenance of the equipment, which should be done daily by the institution of an appropriate system (T.73). 4.10 In this case, the outcome may not have been any better even if the oxygen equipment was working, since Mrs. Czekajlo’s airway was blocked and no oxygen could get past the obstruction (T.80). 4.11 Ms. Walters told me that in her opinion a member was at fault, in that the last person to use the oxygen cylinder should have put a sign on it if it was faulty or empty, and the maintenance staff would have attended to it the next day (T.48). She said that this has been reinforced to staff. 4.12 The use of the Heimlich manoeuvre was also questioned. Ms. Ashby said that the Resuscitation Council of Australia recommend lateral chest thrusts with the patient on their side on the floor, so that there is less danger of damage to vital organs (T.74), particularly in the elderly. She acknowledged, however, that opinions vary on the subject (T.80). 4.13 Ms. Walters said that, although the Resuscitation Council published their program in 1995, the St. John Ambulance did not teach that method as part of their senior first aid certificate in 1997 when staff last underwent training (T.39). 4.14 Lateral thrusts are now taught by St. Johns (they did so in a course in 1999) (T.40). 4.15 Ms. Walters was unable to accept the evidence of Ms. Hosking that she was unable to get Mrs. Czekajlo on the floor because she had just returned from major surgery. Ms. Walters said that she was to do her normal duties” (T.40). It seems that there “able may have been some communication problems in relation to Ms. Hosking’s fitness for work. Perhaps, because lateral thrusts were not used at TLH in January 1999, it was not foreseen that she would need to do so. Hopefully, now that this method is taught, such misunderstandings will not re-occur. 4.16 What is important is that staff receive regular training in choking management and resuscitation so that they can retain their skills, even though such events are rare (T75). 5. Conclusions
4.9 The difficulties the staff encountered with the oxygen equipment were indicative of a lack of appropriate checking and maintenance of the equipment, which should be done daily by the institution of an appropriate system (T.73). 4.10 In this case, the outcome may not have been any better even if the oxygen equipment was working, since Mrs. Czekajlo’s airway was blocked and no oxygen could get past the obstruction (T.80). 4.11 Ms. Walters told me that in her opinion a member was at fault, in that the last person to use the oxygen cylinder should have put a sign on it if it was faulty or empty, and the maintenance staff would have attended to it the next day (T.48). She said that this has been reinforced to staff. 4.12 The use of the Heimlich manoeuvre was also questioned. Ms. Ashby said that the Resuscitation Council of Australia recommend lateral chest thrusts with the patient on their side on the floor, so that there is less danger of damage to vital organs (T.74), particularly in the elderly. She acknowledged, however, that opinions vary on the subject (T.80). 4.13 Ms. Walters said that, although the Resuscitation Council published their program in 1995, the St. John Ambulance did not teach that method as part of their senior first aid certificate in 1997 when staff last underwent training (T.39). 4.14 Lateral thrusts are now taught by St. Johns (they did so in a course in 1999) (T.40). 4.15 Ms. Walters was unable to accept the evidence of Ms. Hosking that she was unable to get Mrs. Czekajlo on the floor because she had just returned from major surgery. Ms. Walters said that she was “able to do her normal duties” (T.40). It seems that there may have been some communication problems in relation to Ms. Hosking’s fitness for work. Perhaps, because lateral thrusts were not used at TLH in January 1999, it was not foreseen that she would need to do so. Hopefully, now that this method is taught, such misunderstandings will not re-occur. 4.16 What is important is that staff receive regular training in choking management and resuscitation so that they can retain their skills, even though such events are rare (T75). 5. Conclusions
CZEKAJLO%20Helena.docx