An intellectually disabled woman with obstructive sleep apnoea may have died from pneumonia contracted from a CPAP machine that was not regularly cleaned by her care provider, a coroner has concluded.
The 44-year old woman who lived in a residential care facility in Melbourne had been diagnosed with OSA in 2013 and provided with a CPAP machine by Western Health.
But the Victorian coroner investigating her death from a lung abscess in 2019 found that her care provider, Annecto, had not followed the written instructions provided by the Western Health CPAP Service on maintenance and cleaning schedules for the machine.
When reviewed at the outpatients clinics, the woman, assisted by her father, had shown some ability to apply her CPAP mask and chinstrap, but due to her intellectual disability, she was not deemed capable of independent use, operation or cleaning of CPAP equipment.
The service provided verbal and written instructions to her carers, warning that the warm and humid environment of the heated tubing in the CPAP machine could potentially result in fungal, mould and yeast growth that could be blown directly into the user’s lungs, posing a risk of pneumonitis, bronchitis and pneumonia.
The patient and her father were given a cleaning schedule for the machine emphasising the need for the mask and tubing to be washed and dried regularly, filters cleaned and replaced and the humidifier chamber to be emptied, cleaned and have be replenished with clean water daily.
The coroner noted that the CPAP machine instructions and cleaning schedule had been given to care staff who attended appointments with the patient at the Western Health CPAP clinic and were also passed on to the facility by her father.
Western Health understood that the care facility or family (depending on where she stayed) were to supervise her therapy and maintain her equipment.
But the patient’s father said he did not believe the machine was being cleaned by staff at the residential care facility, based on his observations when she came to stay at home.
“I had observed the compartment was always filthy from the use of tap water. I always utilised filtered water in the machine to eliminate this issue. I often observed relief staff working at the care facility that were not familiar with Melissa’s needs. I believe this was due to inadequate staffing within the facility,” he said.
The care provider told the coroner that it was their policy for residents to manage their own health procedures if a doctor or healthcare provider had provided training.
However the facility had no documentation to show that the patient had demonstrated such capability or that there was any assessment or monitoring of her ability to operate and clean the CPAP machine independently.
The coroner concluded that the woman’s death was from complications of a lung abscess which may have been caused or contributed to by bacteria and/or mould growth in her CPAP machine.
“I consider that it is possible that Melissa’s death may have been prevented if the CPAP machine had been adequately cleaned in accordance with the cleaning schedule provided by Western Health,” she concluded.
The coroner issued recommendations for the care provider to develop and implement procedures to ensure that residents with CPAP machines have assessments as to whether they are able to independently use, operate and clean the machine.
Such assessments and management procedures should be accompanied by regular monitoring and reviews that are documented as part of care plans in conjunction with clinical staff, she added.