The death of a 75-year-old Castlederg woman in March 2023 was directly influenced by a cardiac arrest caused by an empty oxygen tank, an inquest in Belfast has heard.

Mary Elizabeth Glenn passed away at the South West Acute Hospital in Enniskillen on March 31, 2023. A post mortem listed pneumonia and heart disease as causes, but expert testimony described a different chain of events.

Dr Martin Stotz, an anaesthetist and ICU consultant, told the coroner that the empty tank starved Mrs Glenn of oxygen, triggering the cardiac arrest. He said that without that event she had an 86 per cent chance of survival.

Earlier evidence from nursing staff revealed confusion over oxygen tank policies. Nurse Aisling O’Brien, who was in charge of the ward on March 22, said she had no formal training on the use of Airvo oxygen equipment and was unaware of a 2020 safety alert about moving patients on assisted oxygen. She also said she did not know of any specific policy for oxygen tank size, stating she would have used a 15-litre tank. However, nurse Anna Kudama told the inquest that Ms O’Brien instructed her to use a three-litre tank, claiming it was in line with trust policy. Ms O’Brien denied this.

The inquest was told that a do-not-resuscitate notice for Mrs Glenn was not acted upon. Dr Stotz said the medical team should have spoken with the family about the DNR in the 45 hours before the cardiac arrest. The successful resuscitation prolonged her suffering in her final days, he said, calling the sequence a failure of duty of care.

A Serious Adverse Incident report by the Western Health and Social Care Trust outlined ten recommendations, including a policy on transferring patients requiring oxygen and appointing a dedicated staff trainer to address gaps in training.

The inquest continues. Doctors involved in the resuscitation are expected to give evidence at Laganside Courthouse.