Ventilator pause likely 'cut the thread of life’ for Builth Wells woman - coroner

A ventilator failure was “likely to be the last event that cut the thread of life” that a Builth Wells woman was hanging from, a coroner has said.

South Wales Central area coroner Graeme Hughes will write to the NHS in Wales and England to highlight the risks of battery depletion in ventilators, to try and prevent a similar incident happening again.

He also asked for an update on a transfer to a different ventilator model at the University Hospital of Wales, Cardiff.

Angela Josephine Foster was a very sick woman when she reached the University Hospital of Wales in Cardiff on January 11, 2025.

The 59-year-old had fallen down the stairs at her home in Cwrt y Castell, Builth Wells at around 5am when it is believed she may have hit her head. She lost consciousness and suffered several cardiac arrests.

Her partner David Dean said in a statement they had ordered a Chinese takeaway and went for a drink where Angela drank two pints. At home she drank another five cans with their food. They went to bed, she was merry and at 5am he heard a loud bang and found her at the bottom of the stairs.

An inquest at Pontypridd Coroner’s Court on Monday (April 20) heard that a Welsh Ambulance Service community first responder was first at the scene. Tony Dudley placed the defibrillator pads on Ms Foster’s chest but no shock was advised “a couple of times”. He took over CPR from Mr Dean until a paramedic arrived.

Dr Louise Webster from Wales Air Ambulance was concerned Ms Foster had suffered a significant head injury and she said in a statement she was concerned about the amount of adrenaline required to try and keep her blood pressure stable.

She said she did not think Ms Foster would survive the transportation to the hospital or make a meaningful recovery.

Her condition stabilised so she was flown to the University Hospital of Wales in Cardiff. But in flight her condition deteriorated.

At the hospital Dr Nicholas Weston-Smith was concerned about her prolonged period in cardiac arrest and she was taken for a CT scan and placed on a ventilator.

A little while later he noticed a pause in ventilation and an alarm for a low battery sounded at 8.45am. He and another colleague manually ventilated her and he said in a statement Ms Foster was without oxygen for 30 seconds to one minute.

Shortly afterwards she suffered a further cardiac arrest and a decision was made not to commence CPR because of her poor prognosis.

Dr Rachael Harding said no traumatic brain injury could be seen on the CT scan but it was agreed Ms Foster was in a terminal condition and to continue supportive treatment until her family arrived at the hospital.

She said: “The ventilator pause may have contributed to the timing of Angela’s death but I think her death was inevitable in minutes or hours.”

Pathologist Dr Thomas Hockey said Ms Foster had a build-up of fatty deposits in her artery and under a microscope there were bruises to parts of the brain in keeping with a fall.

He recommended an indeterminate cause of death but said ventilator breakdown, hypoxic ischemic brain injury caused by lack of oxygen, heart attack (myocardial infarction), and atherosclerosis, deposits in her arteries, contributed to Ms Foster’s death.

Dr Olimpia Curran, neuropathologist, confirmed the small bruises at the front of the brain.

Dr Michael Harrison said it was likely the ventilator’s battery ran out because it had not been charged overnight. He said changes have been made to the ventilators and a new checking procedure has been put in place to try and reduce the risks of the ventilator pausing again.

Mr Hughes accepted the medical cause of death as presented by Dr Hockey.

He said the ventilator pause had not materially contributed to Ms Foster’s brain injury; though it likely contributed to the timing of her death but not its underlying causation.

He said both the brain injury and heart attacks were drivers for her death but there was no way of knowing why she fell down the stairs. He said it could have been due to the influence of alcohol or a medical event which made her collapse and fall.

Mr Hughes praised the “commendable and appropriate actions” of the emergency services and he said all of the medical professionals were consistent in their poor prognosis for Angela.

He said it was more likely that Dr Weston-Smith acted promptly when the ventilator paused.

“It was likely the last event that cut the thread of life that Angela was hanging from at that time,” Mr Hughes said.

He returned a narrative conclusion – Ms Foster died of a combination of natural causes and complications of trauma and disease after a fall or collapse at home.

He directed Dr Harrison to update him by July 31 about the transfer of ventilators at the hospital from Oxylog 3000 to Hamilton Mode and for him to check with Llandough Hospital on their ventilator models and whether they have changed them or intend to.

Mr Hughes said he would also write to the NHS in Wales and England to highlight the risks of battery depletion in ventilators so they can take action to mitigate against the risks of a similar occurrence in the future.

He passed on his deepest condolences to Ms Foster’s family.