A much-loved dad was discovered dead in a hospital side room after no alarm sounded when his ventilator failed, an inquest has heard.

Father-of-three Keith Rogers, 49, was found unresponsive at the QEQM in Margate after the life-saving machine turned off and disconnected – depriving him of vital oxygen.

Staff had not been trained to properly set up the ventilator, so its alert system was not activated to inform healthcare professionals it had failed and Mr Rogers was in trouble.

An additional alarm monitoring his heart rate was also not loud enough to be heard by anyone outside of the room.

A coroner said at the two-day inquest that the life of Mr Rogers would “more likely than not have been significantly extended” if the machine had not turned off.

His death is at least the second at the East Kent Hospitals Trust to have been linked to the failure of vital alert systems in recent years, with a 65-year-old man suffering fatal brain damage at the Kent and Canterbury Hospital in March 2021.

On that occasion the alarm volume was too low to alert staff that the patient, Christopher Osland, had suffered a cardiac arrest.

“I sincerely hope the trust has learned lessons from this case to ensure no other families have to suffer in the same way that Keith’s family have...”

The trust’s chief nursing officer said at an inquest into Mr Osland’s death last year that it had “made a number of changes to ensure this does not happen again”.

But it has now emerged a second death had occurred because of a lack of staff training, with Mr Rogers dying in similar circumstances just five months after Mr Osland.

The Herne Bay resident had been admitted to the QEQM Hospital in August 2021 with respiratory failure.

The IT trainer, who worked at Sheppey Prison, was put on a form of ventilation known as BIPAP, where oxygen is delivered through a tube connected to a mask placed over a patient’s mouth.

Traditionally, BIPAP is used on respiratory wards and on high-dependency units, with close supervision of the patient. However, due to concerns about the machine generating infectious aerosols that could promote the spread of Covid, Mr Rogers was placed in a closed side room.

Two days into Mr Rogers’ stay, a healthcare assistant entered his room and heard an alarm sounding from the cardiac machine, with the patient appearing grey and unresponsive.

An investigation found the BIPAP machine had turned off – and the tube that connected the mask and the machine had physically disconnected.

The inquest in Maidstone heard many staff – including the two on the ward that day – had not been trained in the set-up of the ventilator, and so had not known that the default setting of the machine’s alarm was set to “off”.

Because of this, no alarm sounded from the ventilator when it turned off or disconnected. The cardiac alarm was also not set at a high enough volume to be heard outside the room when the door was closed. It was not until the healthcare assistant entered the room that it was heard.

Consultant John Collins, an expert witness, said that he would have “hoped” to see a patient of Mr Rogers’ vulnerability checked every 15 minutes, but said in the circumstances he would have expected checks every 30 minutes. He added that two minutes off the machine would have caused brain damage, and 10 minutes would have been fatal.

“A full investigation has been carried out and we have made changes to prevent such a tragic event from reoccurring...”

Mr Rogers was listed as being checked hourly, but the healthcare assistant entered the room between 30 and 40 minutes after he was last examined.

The inquest was told Mr Rogers had a number of long-standing health issues, including paralysis in his right arm following a motorcycle crash.

He also had a rare condition called an arteriovenous malformation (AVM) in his left arm, which is known to put pressure on the heart and lungs and led to the amputation of all four fingers on his left hand.

Despite this, he was able to work full time, and could operate most things in his home using an Amazon Alexa device and other voice-activated tools.

At the inquest, Mr Rogers’ cause of death was given as respiratory failure, with chronic pulmonary obstructive disorder listed as a contributory factor.

Recording a narrative verdict, coroner Joanne Andrews said it was not possible to establish how or when the tube became detached, or the machine turned off.

She added: “If the BIPAP treatment had continued [Mr Rogers] would not have died when he did and his life would have more likely than not have been significantly extended.”

Simon Turner - a legal representative for East Kent Hospitals - informed the court that a number of changes had been made as part of an action plan in the aftermath of the tragic incident.

This included training for all members of staff for the BIPAP machines – which the trust said had not been completed due to the pressures of the pandemic – as well as technical alterations to ensure the alarm default was set to “on”.

Mr Turner also said that with the easing of pandemic pressures, patients on BIPAP were no longer kept in side rooms – although there was no policy in place to ensure it did not happen again.

Ms Andrews told the court she would write to the trust to express her concern that no such policy existed, but did not state any immediate intention to enforce legal action.

Speaking to Mr Rogers’ family, she added: “I am so very sorry for your loss. I hope now that [the inquest] has concluded it gives you some of the answers that as a family you had, and now you will have the chance to remember a man who was very, very much loved, and very much missed by you all.”

Speaking after the inquest, the family’s legal representative, Michelle Meakin, said: “I was concerned to note that the trust still doesn’t have a protocol in place should patients on non-invasive ventilation have to be nursed in closed side rooms again.

“I sincerely hope the trust has learned lessons from this case to ensure no other families have to suffer in the same way that Keith’s family have.”

Jane Dickson, the chief nurse at East Kent Hospitals, said: “I offer my heartfelt condolences to the family of Mr Rogers and I am truly sorry for their loss. The Trust acknowledges and accepts the findings of the coroner.

“A full investigation has been carried out and we have made changes to prevent such a tragic event from reoccurring, which includes all staff who care for patients on the new BIPAP machines undertaking further training, and information on manually setting the alarms has been reinforced at staff handovers.

“A checklist has been developed which has to be completed by staff using the machine and this includes ensuring that the alarm setting is on.”