Safety rules ignored before diabetic man bled to death, inquest hears
Rules to stop dialysis tubes being covered were ignored by hospital staff when a diabetic man bled to death while having treatment, an inquest heard.
A national alert issued in June 2018 following three near-miss events was also not distributed before the death of 31-year-old Mohammed Ismael "Bolly" Zaman at Royal Shrewsbury Hospital.
Pharmacy dispenser Bolly, from Telford, died on October 18, 2019, when he lost nearly half of his circulating blood after his machine became disconnected while he was having dialysis. His family is suing the hospital
At his inquest at Shirehall, dialysis assistant Sheilon Santiago, who helped connect Bolly to the machine before his treatment started, gave evidence.
He described giving Bolly three blankets to keep him warm due to the cold temperature of the room, ignoring guidance which says tubes should be left exposed for medics to be able to keep an eye on what's going on. Mr Santiago, who was caring for Bolly for the first time, said he had seen senior staff cover up before so thought it was OK.
David Tyack, representing the Zaman family, asked Mr Santiago: "As far as you were concerned, it wasn't allowed for access to tubes to be covered, but he covered himself with a blanket. Didn't you think this was against the rules?"
Mr Santiago replied: "I've seen him covered before so I thought it was allowed by senior staff. In my mind, it was allowed.
Mr Tyack added: "You said if you saw someone cover themselves with a blanket, you should report it. But you didn't in Bolly's case."
Mr Santiago said: "In my mind, it was OK. It was quite a common thing."
He accepted that it was common sense not to cover the tubes.
The inquest previously heard that a key issue relating to Bolly's death was that an unidentified member of staff pressed the "reset" button on his machine when the alarm went off, without checking the tubes.
Bolly lost three pints of blood in seven minutes, went into cardiac arrest and died.
Coroner John Ellery asked Mr Santiago if it was him who pressed the reset button.
"No sir," he replied.
Mr Santiago described Bolly giggling when he leant in to check on his breathing while he was having treatment, and when his patient caught him singing while working on the ward.
He was also asked whether he had heard about the June 2018 alert, but said he had not. Department lead Johann Nicholas, a consultant nephroplogist, said he did not remember distributing the information, and accepted there had been "systemic failings" in training at the hospital.
The inquest continues.
