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.