On Ist February 2011 commenced an investigation into the death of Joanne Elizabeth Oliver; aged 31 _ The investigation concluded at the end of the Inquest without a jury on 3r April 2014. The conclusion of the inquest was: The Cause of death was:
1.a. Multiple Organ Failure
1.b. HINI Influenza (treated) I: Obesity The Conclusion was: Narrative Conclusion Joanne had been a patient at the Freeman Hospital in Newcastle where she had been receiving ECMO treatment for HINI flu, known as swine flu On the 17lh January 2011 Joanne was transferred from the Freeman Hospital to the Manchester Royal infirmary by air ambulance. During the course of the journey her condition deteriorated, but by adjusting her ventilation and medication it was possible to keep her stable She was received as an inpatient into the Intensive Care Unit at Manchester Royal Infirmary where she was ventilated and received medication. Unfortunately her condition deteriorated further and at 8.40 pm she went into cardiac arrest and died at 9.16pm the same day: CIRCUMSTANCES OF THE DEATH: Joanne Oliver was aged 31. In early December 2010 she began to suffer from '"flu symptoms and went to see a GP on the 7lh December who diagnosed iower respiratory tract infection, prescribed Amoxicillin and Codydramol and gave safety net advice. On the 13"h December Joanne went to a "walk in" health centre who immediately arranged for her to be admitted to The Royal Oldham Hospital. There she was diagnosed as suffering from HINI , swine 'flu: She was ventilated but her condition worsened and on the 1gh December 2011 she was admitted for ECMO treatment to The Freeman Hospital in Newcastle Shehad a stormy period of treatment but by_the_12 January 2011 she was weaned off like

ECMO. She had improved by Friday January to the extent that it was agreed to repatriate her by road ambulance to the Manchester Royal Infirmary (MRI): That attempt was cancelled because when Joanne was transferred to the transport ventilator she quickly developed respiratory acidosis due to her inability to clear sufficient carbon dioxide, and that in turn induced a supra-ventricular tachycardia. She improved over the following weekend, and arrangements were made to transter her to the MRI on Monday 17ih January 2011 by a specialist team from the NW region led by a consultant in anaesthesia and intensive care , who was skilled in the transfer of critically ill patients. The transfer was to be by helicopter. On the 17lh January her clinical signs indicated that she was stable. She was taken off renal replacement therapy at 11.20am. The consultants and other medical personnel at the Freeman and the Consultant responsible for Joanne's transfer, and who would accompany her; all agreed that she was fit to travel. She was transferred to the travel ventilator and shortly afterwards her blood pressure dropped: The adrenaline was increased and her blood pressure was restored within 5 minutes During the flight to Manchester her end-tidal carbon dioxide level increased which was dealt with by increasing ventilation pressure , and her blood pressure was supported by gradual increases in the rate of adrenaline infusion, additional metaraminol and a bolus of fluid: flight took approximately 1.25 hours At the MRI she was received by an ICU consultant; who took a hand over from the consultant responsible for her transfer and was provided with the Critical Care Transfer Form on which was set out details of Joanne's condition during the flight and the adjustments made to her medications and ventilation. A set of her notes and a Transfer Letter from Newcastle were delivered. She arrived at the MRI at approximately 3pm, and was transferred onto an ITU ventilator which was set slightly higher than the travel ventilator setting to help clear her CO2. It was not possible to take blood from an existing arterial line for blood gas analysis, and blood was not taken from the existing venous lines. The doctor who was looking after Joanne read her file and made notes. He had also other patients t0 look after: By 6pm (3 hours after arrival) a plan was made to insert a new arterial line , but unfortunately that proved difficult and it was not until around 8pm that he was successful: A blood sample for gas analysis was taken and the results at 8.11 pm, showed severe metabolic acidosis with high levels of CO2 and potassium. By that time she had been present at the MRI for 5 hours and off renal replacement therapy for 9 hours. Emergency treatment was given to try t0 reverse this but half an hour later; at 8.40pm, Joanne suffered a cardiac arrest and despite CPR she died at 9.16pm. It was accepted by the MRI that the delay in obtaining blood for gas analysis, and subsequent monitoring; was unacceptable. The transfer from the Freeman t0 the MRI was with a background of pressure on the Freeman that once a patient had completed their ECMO treatment their bed should be released to another patient requiring ECMO treatment "We were in the middle of a swine flu epidemic and there was great demand on ECMO facilities and ICU beds throughout the country"

In my opinion action should be taken to prevent future deaths and believe that the Intensive Care Society has the resources and power to prepare the necessary guidelines referred to and advise your members to comply with the guidelines